Feature Story

National studies examine excess work hours among medical interns and the risk for needlestick injuries

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) introduced work-hour limits for all first-year residents training in U.S. hospitals. Under these standards, interns are limited to a maximum of 30 consecutive work hours (known as the 30-hour rule), which includes time used for sign-out, teaching, and continuity of care. Interns are also prohibited from working more than 80 hours per week (the 80-hour rule), averaged over 4 weeks, and must be free of all duties for 1 day in 7 (the 7-day rule). In the year following implementation of the standards, mandatory reports submitted to the ACGME by residency programs concluded that only 5 percent of residency programs did not comply, and only 3 percent of residents reported any violations of the 80-hour rule. However, a study, funded in part by the Agency for Healthcare Research and Quality (HS12032), found that nearly 84 percent of medical interns reported they continue to work hours that exceed the ACGME limits. A related study (HS12032 and HS14130) concludes that interns are much more likely to injure themselves mistakenly with a needle or another sharp instrument when working in a hospital more than 20 consecutive hours, or at night. Both studies are discussed here.

Landrigan, C.P., Barger, L.K., Cade, B.E., and others (September 2006). "Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits." JAMA 296(9), pp. 1063-1070.

An independent, nationwide study conducted by researchers at Brigham and Women's Hospital, Boston, found that 83.6 percent of interns reported work hours that did not comply with the ACGME standards during at least 1 month in the year (July 2003 through May 2004) following implementation. In the study, Christopher P. Landrigan, M.D., M.P.H., Director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, and colleagues prospectively collected data on interns' work and sleep hours in the year before (June 2002 through May 2003) and after (June 2003 through May 2004) the ACGME standards were implemented. The 4,015 participants completed monthly reports of their work hours and sleep, representing residency programs across all specialties. About 67 percent of interns reported working shifts in excess of 30 consecutive hours. Averaged over 4 weeks, 43 percent of interns reported working more than 80 hours a week, and 43.7 percent reported not having 1 day in 7 free from work duties.

The researchers offer several reasons why non-compliance with the ACGME work-hour rules may be high. Because the standards were created without taking financial or technical implementation into account, residency programs may not have the resources to redesign their programs appropriately. Non-compliance might also be due to a particular medical institution's culture. Some senior physicians have expressed disapproval of work-hour limits, while others do not believe fatigue represents a threat to patient safety.

Ayas, N.T., Barger, L.K., Cade, B.E., and others (September, 2006). "Extended duration work and the risk of self-reported percutaneous injuries in interns." JAMA 296(9), pp. 1055-1062.

Researchers found that interns working during the day following an overnight shift suffered 61 percent more needlesticks and other sharp object injuries than they experienced during a day that was preceded by a night at home (1.3 per 1,000 opportunities versus 0.76 per 1,000 opportunities). Furthermore, interns suffered more than twice as many injuries during the night (1.48 per 1,000) as they did during the daytime (0.7 per 1,000). Lapses in concentration and fatigue were the two most commonly reported contributing factors (64 percent and 31 percent, respectively). These types of injuries may result in transmission of blood-borne pathogens, including hepatitis and HIV.

The study, conducted by researchers at Brigham and Women's Hospital, Boston, and Vancouver General Hospital, Vancouver, British Columbia, surveyed 2,737 interns in U.S. residency programs from July 2002 through May 2003. Najib Ayas, M.D., M.P.H., and colleagues collected monthly data on work schedules and the occurrence of injuries with sharp instruments. These findings build on previous research and the growing awareness that sleep-deprived first-year doctors in training (interns) working traditional 24-hour shifts make many more serious medical errors and crash their cars more often than those whose work is limited to 16 consecutive hours.

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