Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison

Abstract

Background: There are currently no field data about the effect of implementing European Working Time Directive (EWTD)-compliant rotas in a medical setting. Surveys of doctors’ subjective opinions on shift work have not provided reliable objective data with which to evaluate its efficacy.Aim: We therefore studied the effects on patient's safety and doctors’ work-sleep patterns of implementing an EWTD-compliant 48 h work week in a single-blind intervention study carried out over a 12-week period at the University Hospitals Coventry & Warwickshire NHS Trust. We hypothesized that medical error rates would be reduced following the new rota.Methods: Nineteen junior doctors, nine studied while working an intervention schedule of <48 h per week and 10 studied while working traditional weeks of <56 h scheduled hours in medical wards. Work hours and sleep duration were recorded daily. Rate of medical errors (per 1000 patient-days), identified using an established active surveillance methodology, were compared for the Intervention and Traditional wards. Two senior physicians blinded to rota independently rated all suspected errors.Results: Average scheduled work hours were significantly lower on the intervention schedule [43.2 (SD 7.7) (range 26.0–60.0) vs. 52.4 (11.2) (30.0–77.0) h/week; P < 0.001], and there was a non-significant trend for increased total sleep time per day [7.26 (0.36) vs. 6.75 (0.40) h; P = 0.095]. During a total of 4782 patient-days involving 481 admissions, 32.7% fewer total medical errors occurred during the intervention than during the traditional rota (27.6 vs. 41.0 per 1000 patient-days, P = 0.006), including 82.6% fewer intercepted potential adverse events (1.2 vs. 6.9 per 1000 patient-days, P = 0.002) and 31.4% fewer non-intercepted potential adverse events (16.6 vs. 24.2 per 1000 patient-days, P = 0.067). Doctors reported worse educational opportunities on the intervention rota.Conclusions: Whilst concerns remain regarding reduced educational opportunities, our study supports the hypothesis that a 48 h work week coupled with targeted efforts to improve sleep hygiene improves patient safety.

The impact of junior doctors’ worktime arrangements on their fatigue and well-being

“…It is also notable that those who worked >48 hours in the last week experienced markedly more negative effects than those who had worked for ≤48 hours. These findings accord with those of the previously cited intervention study (12) in which doctors working a 48-hour work week demonstrated a substantial reduction in medical errors, compared to doctors on a 56-hour work week.…”

“…In conclusion, it is prudent to recommend on the grounds Tucker et al of patient safety that sequences of no more than 3 or 4 consecutive night shifts be favoured over scheduling 7 night shifts in row, in all but exceptional cases. Recent evidence from an intervention study reported by Cappuccio et al (12) suggests that further reductions in risk may be achieved by reducing the span of nights even further (ie, to spans of 2 or less often 3 consecutive nights). However, the two-shift systems in that study differed on several important parameters.…”

“…Several studies have identified the impact of doctors' work schedules on their cognitive performance (10), susceptibility to making medical errors (11,12), and their well-being (13,14). However, no studies have examined the relative impact of the broad range of shift systems that have been introduced in the wake of the implementation of the EWTD.…”

Excessive Daytime Sleepiness, Sleep Hygiene, and Work Hours Among Medical Residents in India

“…For example, in 2003 in the US, the Accreditation Council for Graduate Medical Education set up legally binding guidelines limiting the work hours to 80 per week and not more than 24 consecutively (Accreditation Council on Graduate Medical Education). Such regulations also exist in Australia (Gander et al, 2007), Canada, the United Kingdom (Cappuccio et al, 2009) and other European countries. Recent recommendations from the Institute of Medicine in the US have reaffirmed the need for stricter adherence (Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, 2008).…”

Shift work, sleep, and sleepiness - differences between shift schedules and systems

“…In a parallel study, the same group showed that extended work shifts (>24 hours) were associated with an increased risk for being involved in a motor vehicle crash [odds ratio (OR) 2.3, 95% confidence interval (95% CI) 1.6-3.3] (83); one may assume that a large part of the crashes were related to sleepliness while driving. Another intervention study among junior doctors showed that a reduction of weekly work hours from 56 to 48 hours resulted in a significant (33%) reduction in medical errors and a tendency towards more sleep (mean daily sleep length: 7.3 versus 6.8 hours for the 56-hour schedule, P=0.09) (84). Thus, the latter studies clearly showed that a very long work week (>80 hours), which includes night work, is a safety risk and should be avoided.…”