Reduced Work Hours for ICU Staff for Patient Safety

描述（由申请人提供）：医疗差错是美国死亡的主要原因。睡眠不足已被证明会严重损害工作表现，并增加工业环境中出错的风险，但医疗保健在采用工作时间改革方面进展缓慢。实习医生仍然经常连续工作30个小时。我们最近发现，在两个ICU中按照传统时间表工作的实习生，比连续工作时间限制在16小时的实习生，发生严重医疗错误的比例高出36%，严重诊断错误的比例高出5倍。然而，尽管有了这一重大改进，但即使在我们的干预证明有效的单位，也没有充分执行减少的工作时间表。广泛实施变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内部工作人员，以及我们最初的干预签名系统存在的问题。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实施两个新的住院工作人员工作时间表，这将消除所有实习生、初级住院医生和高级住院医生在这些环境中的长时间轮班; 2.为了检验假设，与传统的时间表相比，在新的CCU时间表中，住院医生的睡眠以及严重的医疗差错率将得到改善，该时间表消除了所有实习生和高级住院医生的延长轮班，但保留了传统的四舍五入和住院医生的人员配置结构; 3.为了检验这样一个假设，即在经过重组的MICU中，住院人员睡眠和严重医疗差错率也会得到改善，MICU取消了延长的轮班，但也大大改变了人员配备、签出和 四舍五入制度，以支持缩短工作时间，包括启动每天两次的团队查房。 我们提出的前后两个不同的时间表实施策略的研究将推进知识如何最好地减少工作时间，同时尽量减少由于护理不连续性的错误。我们将使用我们已建立的四管齐下的检测方法来确定严重错误率，该方法包括由医生对内部工作人员进行直接，持续的观察，然后对所有事件进行严格的审查。实施每个系统之前和之后的比较将产生开发有效的调度工具所需的信息，该工具可以广泛传播，以减少医生的工作时间，提高全国范围内的患者安全。

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.