Blog | Wednesday, March 27, 2013

QD: News Every Day--Duty-hour regulations may cut into learning opportunities

While housestaff got more sleep working under duty-hour regulations, they had fewer learning opportunities, a study concluded.

To determine the effects of the 2011 Accreditation Council for Graduate Medical Education duty hour regulations compared with the 2003 regulations, researchers conducted a crossover study design among 4 medical house staff teams (43 interns), who were randomly assigned using a 3-month crossover design to a 2003-compliant model of every fourth night overnight call (control, n=560) with 30-hour duty limits or to one of two 2011-compliant models: overnight call every fifth night (Q5, n=420) or a night float schedule (n=140), both with 16-hour duty limits.

Results appeared online March 25 at JAMA Internal Medicine.

Compared with controls, interns on night float slept longer while on call (mean, 5.1 vs 8.3 hours; P=.003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P=.05). However, both models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours, the researchers noted.

For example, interns admitted a higher proportion of patients each month on the control model (79%) compared with the Q5 model (61%) or the night float model (64%) (P less than .001 across groups). Each control intern admitted more patients per month (mean, 24.8) compared with each Q5 intern (mean, 16.5) and night float intern (mean, 17.4), and cared for more patients (mean, 31.5) compared with each Q5 intern (mean, 27.0) and night float intern (mean, 27.2).

Both experimental models reduced opportunities to attend a daily noon conference by 25%, researchers noted.

Control interns worked a mean of 39 hours per week between 8 a.m. and 6 p.m., which was 30% more than Q5 interns and 13% more than night float interns.

Handoffs between interns increased from 3 in the control model to as high as 9, a 130% to 200% increase, in the experimental models. Control models involved a minimal number of 3 different interns caring for a patient compared to 5 for the experimental models, a 33% to 67% increase.

Finally, residents and nurses in both experimental models perceived reduced quality of care, so much so with night float that it was terminated early.

Researchers wrote, "This disruption in education can reduce the effectiveness of training programs' current provision of formal and informal curricula. Our models preserved 2-hour morning bedside rounds led by our assistant chief of service, a cornerstone of our educational curriculum. However, interns on our experimental models were on the wards less during standard work hours and had fewer opportunities to work with our faculty, consultants, and other health care professionals who are present more often during these hours."