Reduced Work Hours for ICU Staff for Patient Safety

描述(由申请人提供)：在美国，医疗差错是主要的死亡原因。事实证明，在工业环境中，睡眠不足会显著损害工作表现，增加出错的风险，但医疗保健部门在采取工作时间改革方面进展缓慢。接受培训的医生仍然经常连续工作长达30个小时。我们最近发现，在两个ICU按传统时间表工作的实习生犯下的严重医疗错误和严重诊断错误，比连续工作16小时的实习生高36%和5倍。然而，尽管有了这一实质性改进，但即使在我们的干预被证明有效的单位，也没有充分执行减少的工作时间表。广泛实施改革的障碍包括我们之前的研究重点是实习生，而不是所有的房屋工作人员，以及我们最初的干预签约系统存在的问题。为了更有效地减少医生的工作时间，同时解决我们先前干预研究的局限性，我们提出以下建议： 1.在MICU和CCU实施两个新的住院部工作人员工作表，取消这些环境下所有实习生、初级住院医生和高级住院医生的延长轮班； 2.为了检验这样一种假设，即与传统时间表相比，新的CCU时间表将改善住院部工作人员的睡眠和严重医疗差错率，该时间表取消了所有实习生和老年住院医生的延长轮班，但保留了传统的查房和房务干事的人员结构； 3.为了测试这样一种假设，即在重组的MICU中，内部员工的睡眠和严重医疗错误率也将同样改善，该MICU消除了长时间的轮班，但也大幅改变了人员配备，注销，并 支持缩短工作时间的巡回制度，包括启动每天两次的团队巡回。 我们提议的对两种不同的时间表实施策略的事前-事后研究将促进人们对如何最好地减少工作时间，同时将护理中断造成的错误降至最低的了解。我们将使用我们建立的四管齐下的检测方法来确定严重错误率，其中包括医生直接、持续地观察医院工作人员，然后对所有事件进行严格审查。对每个系统实施前后的比较将产生开发有效的日程安排工具所需的信息，该工具可以广泛传播，以减少医生的工作时间，并在全国范围内提高患者的安全。

DESCRIPTION (provided by the applicant): Medical error is a leading cause of death in the United States. Sleep deprivation has been proven to significantly impair performance and increase the risk of error in industrial settings, but health care has been slow to adopt work hour reforms. Physicians-in-training still routinely work up to 30 hours in a row. We recently found that interns working a traditional schedule in two ICUs made 36 percent more serious medical errors and 5 times as many serious diagnostic errors as interns whose consecutive work was limited to 16 hours. Despite this substantive improvement, however, full implementation of a reduced work schedule has not occurred, even in the units where our intervention proved effective. Barriers to broadly implementing change have included our prior study's focus on interns rather than all house staff, and perceived problems with our initial intervention signout system. To more effectively implement reduced work hours for physicians, while addressing the limitations of our prior intervention study, we propose the following: 1. To implement two new house staff work schedules in a MICU and CCU, which will eliminate extended shifts for all interns, junior residents, and senior residents in these settings; 2. To test the hypothesis that compared with a traditional schedule, house staff sleeps as well as serious medical error rates will improve in a new CCU schedule that eliminates extended shifts for all interns and senior residents, but retains a traditional rounding and house officer staffing structure; 3. To test the hypothesis that house staff sleep and serious medical error rates will likewise improve in a restructured MICU that eliminates extended shifts, but also dramatically alters staffing, sign out, and rounding systems to support shorter work hours, including the initiation of twice-daily team rounds. Our proposed before-after study of two distinct schedule implementation strategies will advance knowledge of how best to reduce work hours while minimizing errors due to care discontinuities. We will determine serious error rates using our established four-pronged detection method that includes direct, continuous observation of house staff by physicians, followed by rigorous review of all incidents. Comparisons before and after implementing each system will yield information needed to develop an effective scheduling tool that can be widely disseminated to reduce physician work hours and improve patient safety nationwide.