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(Chest. 2006;130:625.)
© 2006 American College of Chest Physicians

Bekele Afessa, MD, FCCP; Joseph C. Kolars, MD and Rolf D. Hubmayr, MD, FCCP

Rochester, MN

Correspondence: Bekele Afessa, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905; e-mail: afessa.bekele{at}mayo.edu.

To the Editor

We thank Drs. Wise and Frost for their letter about our article (December 2005).1 We agree that the suboptimal length and pattern of the shifts may have played confounding roles in our study. There are large differences in physicians’ working hours between Europe and the United States. The European Working Hour Directive limits physicians in training to work a maximum of 58 h/wk.2 In the United States, the Accreditation Council for Graduate Medical Education limits the working hours of residents and fellows to 80 h/wk.3 Compared to the traditional work hours in many teaching institutions in this country, our shift model represented a step forward. There are powerful drivers of change in organization and delivery of critical care in this country. Concerns for patient safety and the efficient utilization of limited resources are fueling a debate on critical care training requirements, accreditation, optimal staffing models, and sustainable work hours.45 Prolonged working hours compromise both patient safety and housestaff education.67

Drs. Wise and Frost also highlight the importance of 24-h intensivist staffing in order to improve patient outcomes. Although such staffing is unlikely to be universally implemented because of the shortage of critical care providers,8 their comment is well supported by several publications.9 Indeed, we know that consultant presence at the bedside increased as a byproduct of our resident shift work trial. However, as already acknowledged, our study was likely underpowered to demonstrate beneficial effects on patient outcomes. In recognition of the importance of intensivist presence at the bedside, we have recently implemented an in-house shift model for consultants and hope to describe the impact of this new staffing model on patient outcome as well as housestaff education in the future.

Footnotes

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be disclosed in this article.

References

  1. Afessa, B, Kennedy, CC, Klarich, KW, et al (2005) Introduction of a 14-hour work shift model for housestaff in the medical ICU. Chest 128,3910-3915[Abstract/Free Full Text]
  2. Pickersgill, T The European working time directive for doctors in training [editorial].BMJ 2001;323,1266[Free Full Text]
  3. Accreditation Council for Graduate Medical Education. Report of ACGME work group on resident duty hours. June 11, 2002. Available at: www.acgme.org. Accessed July 20, 2006
  4. Institute of Medicine.. Crossing the quality chasm: a new health system for the 21st century 2004 National Academies Press Publications. Washington, DC:
  5. Institute of Medicine.. To err is human: building a safer health system 2000 National Academies Press Publications. Washington, DC:
  6. Landrigan, CP, Rothschild, JM, Cronin, JW, et al Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351,1838-1848[Abstract/Free Full Text]
  7. Lockley, SW, Cronin, JW, Evans, EE, et al Effect of reducing interns’ weekly work hours on sleep and attention failures. N Engl J Med 2004;351,1829-1837[Abstract/Free Full Text]
  8. Ewart, GW, Marcus, L, Gaba, MM, et al The critical care medicine crisis: a call for federal action; a white paper from the critical care professional societies. Chest 2004;125,1518-1521[Abstract/Free Full Text]
  9. Pronovost, PJ, Angus, DC, Dorman, T, et al Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288,2151-2162[Abstract/Free Full Text]




This Article
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