[dnautics]

Didn't they do a study and find that decreasing doctor hours caused an increase in patient mortality because of handoff errors? And that digitizing records didn't help because of a combination of inaccurate measurement by the staff and because of factors that can't be measured (intuitive observation, etc).

[Peradine]

There are certainly handoff errors, but the vast majority of these can be avoided with a well structured handoff with safety-checks built in. The problems that make handoff bad include:

1) Handoff being done at the end of a long shift, so the doctors handing off their patients are tired, sick of working, and desperate to go home

2) Handoffs being interrupted by sick patients (understandably so) - I was once in a handoff that was abandoned half way through because of a cardiac arrest that half the team had to run off to

3) Rubbish handover systems - most hospitals use hand written notes on scraps of paper carried round by doctors; these can be lost, misread, or accidentally forgotten. There are some technological solutions being developed, but few hospitals have employed them so far

[j-pb]

Proposal: Have doctors always work in pairs like we do when pair programming. The shifts of each partner consists of 8 hours but are shifted by half a phase. This way the maximum time of sleep deprivation is 4 hours and the handoff is also a process that takes 4 hours giving maximum information transfer and always a fresh mind to catch errors.

[theluketaylor]

Or doctor/nurse practitioner pairs, since training and paying a NP is far cheaper.

[maxerickson]

We don't have enough doctors to do that.

[npizzolato]

By design.

[cc439]

Failed handoffs are a process issue and working doctors and nurses harder is just a bandaid on a broken process. I'm viewing this from a manufacturing quality system perspective and while manufacturing a product is far different from treating a patient in a hospital, at the core they are both processes.

There are far more variables involved in successful medical care but the disparity in failure rates is just too large for me to believe that the idea of QA/QC in the healthcare system is anything more than an afterthought.

[rhino369]

I wonder if they could work in a napping system that compensates for the lost sleep. Several 45 minutes naps can do a lot if they are working 30 hours straight.

[vorotato]

Who is this they?

[TJSomething]

That would be Desai, et al. Though I can't access the paper right now, they say that the 2011 regulations have tripled handoffs, increasing handoff risk. It also turned out that the average amount of sleep per week was not increased by much after instituting the regulations.

[1] https://www.sciencedaily.com/releases/2013/03/130325183819.h...

[2] Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 Duty Hour Regulation–Compliant Models on Sleep Duration, Trainee Education, and Continuity of Patient Care Among Internal Medicine House Staff: A Randomized Trial. JAMA Internal Medicine, 2013; DOI: 10.1001/jamainternmed.2013.2973

[chewymouse]

The article is here: http://unmhospitalist.pbworks.com/w/file/fetch/65758972/desa...

[jrowley]

Here is a bit of survey on the topic from April of 2013: https://psnet.ahrq.gov/perspectives/perspective/140/are-resi...

Key finding: "In summary, the literature still does not definitively tell us whether limiting duty hours improves patient safety."

[mattkrause]

I would argue that the literature is basically worthless here, because they're mostly looking at modulations around an absolutely ridiculous baseline. The 2003 changes dropped hours DOWN to 80/week and 16 or 28 per shift.

As an analogy, imagine reducing your cheeseburger intake from 60 per week to 40 per week: it probably won't have a huge impact on physical fitness.

The hand-off issue is also weird because it's at least theoretically improvable, whereas there's no real way (barring go-pills) to reduce sleep-related issues.

[adub]

This study [0] concluded that reduced duty hours for surgical residents actually had no significant difference in patient outcomes.

[0] http://www.nejm.org/doi/full/10.1056/NEJMoa1515724#t=abstrac...

[mattkrause]

That's not really what that study says. The paper finds no difference between a "flexible" schedule and the standard duty-hour one.

Neither one of these schedules is really "reduced" compared to any sort of typical level: they're both ~80 hrs/week (and probably more).

From the paper:

"Programs assigned to the flexible-policy (intervention) group were required to adhere to ACGME duty-hour requirements of limiting work to 80 hours per week, 1 day off in 7 days, and on-call duty no more frequently than every third night, but they were granted a waiver by the ACGME to waive four duty-hour requirements (from the 2003 and 2011 reforms) concerning maximum shift length and minimum time off between shifts (to facilitate continuity of care) (Table 1)"