ICU Resident Shift Length and Effect on Patient Safety

August 24, 2020

Written by Carmen Wolfe

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In this multicenter, cluster-randomized, crossover trial conducted across six pediatric ICUs in the United States, an intervention schedule that eliminated extended work hour shifts resulted in an increased incidence of harmful medical errors by resident physicians.

Why does this matter?
There are mixed findings regarding the patient safety benefits of schedules that eliminate extended shifts for resident physicians. A previously published NEJM study by these authors in 2004 demonstrated an increase in errors among interns who more frequently worked shifts greater than 24 hours. However, later studies have not supported this finding. The FIRST trial showed no change in death or serious surgical complications when shift limits were applied to surgical interns, and the iCOMPARE trial showed no change in mortality among medical patients when shift limits were implemented. Why does shift length seem to have differing effects on patient safety in various studies?

Who needs sleep?
In this clever trial, pediatric ICUs traditionally using extended resident shift schedules were identified, and each site developed its own intervention schedule within the institution’s constraints in order to eliminate extended shifts. Each site served as its own control, matched by time of year. Results revealed wide variability among the sites, with the intervention leading to reduced errors at one site, similar rates of errors at two sites, and increased errors at three sites. So what gives?

The intervention led to a decrease in weekly work hours, an increase in residents’ hours of sleep, and an improvement in residents’ neurobehavioral performance. However, it also created more handoffs and increased resident workload with a higher number of ICU patients per resident during the intervention schedule. When adjusting for this potential confounder, the intervention schedule was no longer associated with an increase in errors. It appears that having a well-rested physician may not translate to better patient safety without also ensuring a safe patient workload.

Source
Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts. N Engl J Med. 2020 Jun 25;382(26):2514-2523. doi: 10.1056/NEJMoa1900669.

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