iCOMPARE RCT - Patient Safety and Resident Duty Hours

Written by Clay Smith

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There was no difference in patient safety between standard resident duty hour restrictions and a more flexible schedule that allowed for longer shifts and no mandated time off between shifts.

Why does this matter?
We know fatigue can increase the chance of making mistakes.  Does a change in duty hour restrictions make patients safer by making physicians-in-training less sleepy?  See the table below for a summary of differences in the two duty hour restrictions.  Yesterday we covered a companion study that did not find a difference in sleep time or alertness with flexible duty hours vs standard.  In 2016, FIRST found no difference in surgical outcomes or quality of life for trainees between differing duty hour restrictions.

Can you practice medicine in your sleep?
This was the same study design as yesterday’s summary, a multicenter RCT comparing standard 2011 duty hour restrictions or a more flexible schedule with no mandate on shift length or time off between shifts (see table below).  The outcome of today’s study was patient-centered instead of trainee-centered.  The primary outcome of 30-day mortality was not inferior in the flexible duty hour group (12.5%) compared to the standard group (12.6%).  There was also no difference in readmission rate or other patient safety metrics.  Duty hour restrictions were first imposed as a result of a sentinel patient safety event.  I trained before the days of duty hour restrictions, and I can attest that it was pretty rough when I walked to my residency program uphill both ways in the snow.  Kidding aside, part of training is caring for patients and being a professional when you’re really tired.  The editorialists ask, “Can we be sure that we are preparing trainees to handle the challenges of practice in the real world where such [duty hour] protections clearly do not exist?”  If the regulations don’t make patients safer and also don’t improve resident quality of life, then what good are they?  I am all for a sane schedule that enhances trainee quality of life and patient safety, but the current regulations don’t seem to be the answer.

Source
Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules.  N Engl J Med. 2019 Mar 7;380(10):905-914. doi: 10.1056/NEJMoa1810642.

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Reviewed by Thomas Davis

From cited article, Supplementary Appendix, Table S1

From cited article, Supplementary Appendix, Table S1

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