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Keeping Patients Safe: Transforming the Work Environment of Nurses Appendix C Work Hour Regulation in Safety-Sensitive Industries1 A substantive body of literature documents the effects of fatigue on worker performance, including the effects of shiftwork and sustained operations on employee alertness. The first section of this appendix reviews this evidence. The second section examines how various health care and non–health care industries have attempted to address consumer and public safety issues by restricting work hours through regulations or administrative guidelines. Since fatigue countermeasures programs are often recommended, a brief overview of these programs and their efficacy is included. Table C-1 at the end of the appendix summarizes hours-of-service regulations in various industries. EFFECTS OF FATIGUE Fatigue resulting from continuous physical or mental activity is characterized by a diminished capacity to do work and is accompanied by a subjective feeling of tiredness. Fatigue may also result from inadequate rest, sleep loss, or nonstandard work schedules (e.g., working at night). Whatever its origin, fatigue has predictable effects, such as slowed reaction time, lapses of attention to critical details, errors of omission, compromised problem solving (Van-Griever and Meijman, 1987), reduced motivation, and decreased vigor for successful completion of required tasks (Gravenstein et 1 This appendix was prepared for the committee to inform its deliberations by Ann E. Rogers, Ph.D., R.N., F.A.A.N., of the University of Pennsylvania School of Nursing.
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Keeping Patients Safe: Transforming the Work Environment of Nurses al., 1990). Thus, fatigue causes decreased productivity; tired workers accomplish less, especially if their tasks demand accuracy (Krueger, 1994; Rosa and Colligan, 1988). Since almost all physiological and behavioral functions are affected by circadian rhythms, the time of day when work occurs is important. Overall capacity for physical work is reduced at night (Cabri et al., 1988; Cohen and Muehl, 1977; Rosa, 2001; Wojtczak-Jaroszowa and Banaszkiewicz, 1974). Reaction times, visual search, perceptual–motor tracking, and short term memory are worse at night than during the daytime (Folkard, 1996; Monk, 1990). On-the-job performance also deteriorates; for example, railroad signal and meter reading errors increase at night, minor errors occur more often in hospitals, and switchboard operators take longer to respond to phone calls (Monk et al., 1996). The human circadian rhythm strongly favors sleeping during the nighttime hours. Although one study notes that nurses working a permanent night shift or rotating shifts obtained more sleep on average than nurses working day or evening shifts, almost one-fifth of the nurses reported having struggled to stay awake while taking care of a patient at least once during the previous month (Lee, 1992). Another study found that falling asleep during the night shift occurred at least once a week among 35.3 percent of nurses who rotated shifts, 32.4 percent of nurses who worked nights, and 20.7 percent of day/evening shift nurses who worked occasional nights (Gold et al., 1992). It was also found that nurses working night or rotating shifts made more on-the-job procedural errors and medication errors because of sleepiness than nurses working other shifts. Sleepiness appeared to be confined to the night shift, as none of the shift rotaters or day/ evening nurses who worked occasional nights reported significant difficulties remaining alert on other shifts. These subjective reports of sleeping on duty were recently verified by both activity (wrist actigraphy) and sleep (polysomnographic) recordings of 15 French nurses who worked at night (Delafosse et al., 2000). Only 4 of the 15 nurses were able to remain awake all night at work; the others averaged 86.5 (standard deviation [SD] ± 77.6) minutes of sleep while on duty. Moreover, difficulties maintaining alertness at night are not confined to nurses; episodes of both subjective (or self-reported) and objective sleep were recorded while U.S. Air Force traffic controllers were on duty at night (Luna et al., 1997), and episodes of drowsiness at the wheel were observed in the majority of 80 commercial truck drivers (Wylie et al., 1996). A person who is not sleep deprived performs tasks more efficiently after prolonged wakefulness and can cope better with nonstandard work hours (nights or rotating shifts) than someone with a sleep deficit (Dinges et al., 1996). Individuals working nights and rotating shifts rarely obtain optimal amounts of quality sleep. Their sleep is shorter, lighter, more fragmented,
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Keeping Patients Safe: Transforming the Work Environment of Nurses and less restorative than sleep at night (Knauth et al., 1980; Lavie et al., 1989; Walsh et al., 1981). Workers are more likely to report greater fatigue at the end of 12-hour work shifts than at the end of 8-hour workshifts (Mills et al., 1983; Rosa 1995; Ugrovics and Wright, 1990). There are exceptions, however: mineworkers reported no differences in fatigue after 8- and 12-hour shifts despite high physical workloads (Duchon et al., 1994), and computer operators reported reduced tiredness throughout the shift after switching from 8-hour to 12-hour shifts (Williamson et al., 1994). Although the timing and duration of meal breaks and “coffee” breaks were not described in these studies, in the case of unionized mineworkers, it is likely they were allowed to stop working for brief periods during their work shift. Sustained operations (shifts of 12 or more hours with limited opportunity for rest and no opportunity for sleep) (Krueger, 1989) often occur among health care providers who staff busy emergency rooms and intensive care units (ICUs), work overtime shifts on nursing units, or work as members of surgical teams that perform lengthy or consecutive procedures (Krueger, 1989). The majority of anesthesiologists and anesthesia residents report having made errors in the administration of anesthesia when fatigued (Gravenstein et al., 1990). The California Nurses Association (CNA) website (CNA, 2001a) reports several serious errors committed by nurses mandated to work 16-hour shifts, in addition to cases in which nurses did not make errors but were at high risk for doing so. For example, a nurse who worked on average one mandatory double shift (16 hours) every 2 weeks for a 2-month period reported that “by 4 a.m. I was so exhausted that I would stop between going from one baby to the next and completely forget why I was going to the other bedside. Another time, again about 4 a.m., I would sometimes stop in the middle of the floor and forget what I was doing.” Studies have shown that accident rates increase during overtime hours (Kogi, 1991; Schuster, 1985), with rates rising after 9 hours, doubling after 12 consecutive hours (Hanecke et al., 1998), and tripling by 16 consecutive hours of work (Akerstedt, 1994). Data from aircraft accident investigations of the National Transportation Safety Board (NTSB) also show higher rates of error after 12 hours (NTSB, 1994a). Finally, night shifts longer than 12 hours and day shifts longer than 16 hours have consistently been found to be associated with reduced productivity and more accidents (Rosa, 1995). Laboratory studies have shown that moderate levels of prolonged wakefulness can produce performance impairments equivalent to or greater than levels of intoxication deemed unacceptable for driving, working, and/or operating dangerous equipment (Dawson and Reid, 1997; Lamond and Dawson, 1998). In one study, performance on neurobehavioral tests remained relatively stable during the first 17 hours of testing, a period the
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Keeping Patients Safe: Transforming the Work Environment of Nurses researchers called the normal working day, then decreased linearly, with the poorest performance occurring after 25–27 hours of wakefulness (Lamond and Dawson, 1998). Performance on the most complex task—grammatical reasoning—was impaired several hours before performance on vigilance accuracy and response latency (20.3 versus 22.3 and 24.9 hours, respectively). Although Dawson and colleagues (Dawson and Reid, 1997; Lamond and Dawson, 1998) were the first to report that prolonged periods of wakefulness (i.e., 20–25 hours without sleep) can produce performance decrements equivalent to a blood alcohol concentration (BAC) of 0.10 percent, numerous other studies have shown that prolonged wakefulness significantly impairs speed and accuracy, hand–eye coordination, decision making, and memory (Babkoff et al., 1988; Florica et al., 1968; Gillberg et al., 1994; Linde and Bergstrom, 1992; Mullaney et al., 1983). The combination of sustained wakefulness and working at night is particularly hazardous (Gold et al., 1992; Smith et al., 1994). When the Exxon Valdez ran aground around midnight on March 23, 1989, the third mate had been awake 18 hours and anticipated working several more hours (Alaska Oil Spill Commission, 2001). Although the explosion of the Challenger space shuttle occurred during the daytime, the decisions made the night before the launch by mission control staff have been cited as a major factor contributing to the explosion (Mitler et al., 1988). The lack of adequate rest periods between workshifts can also exacerbate fatigue. Sleep loss is likely to occur when there are only short durations between work shifts. Most adults require at least 6–8 hours sleep to function adequately at work (Krueger, 1994). The loss of even 2 hours of sleep affects waking performance and alertness the next day (Dinges et al., 1996). After 5 to 10 days of shortened sleep periods, the sleep debt (sleep loss) is significant enough to impair decision making, initiative, information integration, planning, and plan execution (Krueger, 1994). The effects of sleep loss are insidious and until severe, usually are not recognized by the sleep-deprived individual (Dinges et al., 1996; Rosekind et al., 1999). Very short off-duty periods (i.e., 8 hours or less) do not allow for commuting time, recovery sleep, or time to take care of domestic responsibilities (Dinges et al., 1996; Rosa, 1995, 2001). Off-duty intervals ranging from 10 to 16 hours are either suggested or already mandated for many transportation workers (Dinges et al., 1996; Gander et al., 1991b; Mitler et al., 1997). No amount of training, motivation, or professionalism will allow a person to overcome the performance deficits associated with fatigue, sleep loss, and the sleepiness associated with circadian variations in alertness (Dinges et al., 1996; Rosekind et al., 1995). Nor will training, motivation, or professionalism reduce the greater crash risk and increased drowsiness or sleepiness reported by commercial truckers after fewer than 9 hours off duty (McCartt et al., 2000). Recovery from extended work periods requires sev-
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Keeping Patients Safe: Transforming the Work Environment of Nurses eral days; schedules that require workers to return to work after an 8-hour rest period or to transition from night to day or evening shifts without at least 24 hours off are considered particularly dangerous (Olson and Ambrogetti, 1998; Rosa and Colligan, 1988). Fatigue is also exacerbated by increased numbers of shifts worked without a day off (Dirkx, 1993; Knauth, 1993), and working more than four consecutive 12-hour shifts is associated with excessive fatigue and longer recovery times (Wallace and Greenwood, 1995). However, two consecutive nights of recovery sleep can return performance and alertness to normal levels, even following two or three 12-hour shifts (Dinges et al., 1996; Tucker et al., 1996), and longer intervals between works days are even more beneficial. Workers obtain more sleep and start their next shifts with less fatigue. The first or second night in a new series of night shifts, however, may be the most fatiguing because of circadian desynchrony (Rosa, 2001). Predictability of work schedules assists in planning ahead for rest periods. Gold and colleagues (1992) found that nurses who worked rotating shifts reported more accidents than those who were day/evening rotaters. Unscheduled overtime, especially when added to a scheduled work shift, may require 16–20 hours of consecutive work for health care providers and those working in other professions (Rosa, 2001). WORK SCHEDULES OF SELECTED HEALTH CARE PROVIDERS The work schedules of both physicians and nurses, as outlined later in this appendix, are often quite demanding. Although the work hours of truck drivers, locomotive engineers, and pilots are regulated to protect the public from fatigue-related errors, hospitalized patients lack similar protections. At present, there are no restrictions on the number of hours a nurse may voluntarily work in a 24-hour or a 7-day period in the United States. Nor are there restrictions on the number of hours that may be worked by other hospital employees, such as pharmacists (another profession with a developing shortage), and only minimal restrictions exist on hours worked by physicians. Nurses The hours worked by registered nurses (RNs) are of particular concern since they provide the bulk of direct inpatient hospital care; moreover, studies have demonstrated that the care provided by RNs is vital for maintaining the well-being of hospitalized patients (Aiken et al., 2002; Kovner and Jones, 2002; Needleman et al., 2001). RNs must be alert enough to provide safe care for their patients and to recognize potentially dangerous errors in
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Keeping Patients Safe: Transforming the Work Environment of Nurses medication orders. Most previous studies evaluating medical errors took place in environments where nurses had obtained adequate amounts of sleep and were not unduly stressed by workloads, subjected to understaffing, or fatigued from working overtime (Cullen et al., 1997). Today, however, hospital nurses report extremely stressful working conditions, increased numbers of acutely ill patients, inadequate staffing, and working long hours without breaks (Murray and Smith, 1988; Schrader, 2000; Seccombe and Smith, 1996). The effects of these working conditions on patient safety are unknown, but may be significant since a large number of medication errors reported in one study were attributed to poor staffing and onerous work schedules (Leape et al., 1995). Scheduled shifts may be 8, 10, or 12 hours, and may not follow the traditional pattern of day, evening, or night shifts. Although 12-hour shifts usually start at 7 p.m. and end at 7 a.m., some start at 3 a.m. and end at 3 p.m. Nurses working on specialized units, such as the operating room, dialysis units, and some ICUs may be required to be “on call” in addition to their regularly scheduled shifts. Shifts lasting 24 hours are becoming more common, particularly in emergency rooms (ERs) and on units where the nurses self-schedule (personal communications, ER nurse, June 2002, and ICU nurse, September 2002, University of Pennsylvania Hospital). Maintaining adequate staffing levels is a difficult problem, especially during nursing shortages. Hospitals can hire contract staff for specific periods to cover vacant positions or to cope with seasonal fluctuations in demand. Agency nurses, who are not employees of the hospital, can also be used. The use of agency nurses, however, is very expensive, and the quality of care provided by these nurses has been questioned (Brusco et al., 1993). Asking regular nursing staff to work extra hours is often attractive to administrators since it costs less than hiring agency nurses, and the nurses are already familiar with the hospital (Brusco et al., 1993). Furthermore, unless specified in collective bargaining agreements, there are no federal (and only a few state) regulations restricting the number of hours a nurse can work in a 24-hour period or over a period of 7 days. To maintain adequate staffing levels, hospitals frequently offer nurses significant incentives to work extra hours. For example, nurses at the University of Pennsylvania Hospitals are paid time and a half plus an extra $25.00 per hour for working overtime (personal communication, October 2002), while nurses in the University of California system are paid double time (CNA, 2001b). Likewise, nurses at the University of Michigan Medical Center recently approved a contract that requires the hospital to pay 2.5 times their normal wage when they volunteer for overtime in advance (CNA, 2001b). Everyone appears to benefit. When the incentives are high enough, hospital administrators can cover open shifts without hiring additional staff, agency nurses, or traveling nurses, and nurses can significantly increase their
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Keeping Patients Safe: Transforming the Work Environment of Nurses salaries by working extra hours or shifts. The effects on patient care, however, are unknown. The use of overtime, whether mandatory or voluntary, to cope with staffing shortages is quite common in hospital and nursing home settings. Interviews with staff members who worked at 17 nursing homes studied by Louwe and Kramer (2001) revealed that in 13 of the 17 facilities, at least one nursing staff member, and usually more, had worked between one and three double (16-hour) shifts during the previous 7 days. In 5 of the facilities, at least one staff member had worked four to seven double shifts in the last seven days. And in one facility, more than one-third of the nursing staff had worked between eight and eleven double shifts in the past 14 days. Although all direct-care nursing staff (RNs, licensed practical nurses [LPNs]/ licensed vocational nurses [LVNs] and nursing assistants) worked extra hours, the majority of double shifts were worked by nursing assistants. Anecdotal evidence suggests that hospital nurses are also working large amounts of overtime because of short staffing. Nurses continue to report working over 13 hours with only a 20-minute break (Northcott, 1995), and working “four eight hour shifts in two days—32 hours during a 40-hour stretch, leaving the hospital only once for an eight-hour break” (CNA, 2001a). A recent poll conducted by the American Association of Critical Care Nurses (AACCN) indicated that the use of mandatory overtime is also quite common in the United States (AACCN, 2001). Only 40 percent of 2,125 respondents had never been required to work mandatory overtime. Approximately one-third (31 percent) reported working mandatory overtime at least once a month, another 22 percent at least once every 2 weeks, and 7 percent (n = 149) at least once a week. Another poll conducted by the American Nurses Association showed similar results: approximately 60 percent of respondents (n = 4,258) reported being forced to work voluntary overtime (ANA, 2001). Decisions about mandatory overtime are usually made at the last minute, and nurses may receive less than 60 minutes’ notice that they will not be allowed to go home at the end of their scheduled shift (author’s unpublished data). No special accommodations are made for nurses working an extra shift; they are simply assigned a group of patients and expected to provide high-quality care with no additional breaks or a chance to take a short nap between shifts (author’s unpublished data). This practice is particularly dangerous when nurses are required to work extra hours at night. Under such conditions, the nurse may have been awake up to 24 hours, working 16 of those hours and often having only a 30- or 60-minute break. The potential dangers posed by such overtime hours have been clearly documented. For example, the extensive use of overtime has been identified as a contributor to two separate outbreaks of Staphylococcus aureus (Arnow et al., 1982; Russell, et al., 1983). At the time, both hospitals were
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Keeping Patients Safe: Transforming the Work Environment of Nurses contending with an unexpected increase in patient census, coupled with understaffing. Investigations showed that the nurses, who were fatigued and stressed, compromised the usual standards of care by skipping steps or rushing through aseptic procedures. Legislation has been introduced at both the federal and state levels to ban mandatory overtime. Two bills were introduced during the 107th U.S. Congress that would prohibit mandatory overtime for nurses and other licensed health care providers (Golden and Jorgensen, 2002). The first bill2 would amend Title XVIII of the Social Security Act (Medicare Act), while the second bill3 would amend the Fair Labor Standards Act. The Safe Nursing and Patient Care Act of 2001 also contained provisions that would have required the Agency for Healthcare Research and Quality to conduct a study to determine the numbers of hours a nurse can work without compromising the safety of patients. Similar legislation has been introduced in the 108th Congress. State legislatures in approximately 19 states have considered bans on mandatory overtime for nurses and other health care professionals. Most proposed measures prohibit hospitals from requiring nurses to work more than their regularly scheduled 8- or 12-hour shifts. Some bills specify that nurses cannot be required to work more than 40 hours a week, while others prohibit hospitals from requiring employees to work more than 80 hours of overtime in any consecutive 2-week period (Golden and Jorgensen, 2002). Maine’s law (Ch. 401) also mandates that if nurses work longer than 12 hours, they must be given at least 10 hours off before their next shift (Golden and Jorgensen, 2002). To date, bills prohibiting mandatory overtime for nurses have passed in only four states—California, Maine, New Jersey, and Oregon. No measure, either proposed or enacted, addresses how long nurses may work on a voluntary basis. Physicians The hours physicians work, particularly during their residency training, are often quite demanding. Although the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) have recommended that house staff work no more than 80–84 hours per week, it is still common for medical residents to work over 100 hours per week for prolonged periods (Patton et al., 2001). Work days are typically 12–14 hours (Czeisler et al., 2002), and workloads vary by specialty (Patton et al., 2001), with surgical residents typically working 2 Safe Nursing and Patient Care Act of 2001. S. 1686, H.R. 3238 (2001). 3 Registered Nurses and Patient Protection Act. H.R. 1289 (2001).
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Keeping Patients Safe: Transforming the Work Environment of Nurses the longest hours (Committee of Interns and Residents, 2002a; Owens et al., 2001; Silberger et al., 1988). Despite recommendations that work shifts not exceed 24 consecutive hours, many interns and residents remain subject to call schedules requiring duty periods of up to 36 consecutive hours or longer on weekends (Czeisler et al., 2002; Leonard et al., 1998; Owens et al., 2001). Other residents opt to work 60–84 consecutive hours (Friday or Saturday morning through Monday afternoon) in a single “power weekend” each month (Czeisler et al., 2002). The work hours of resident physicians have been the subject of research and frequent debate over the past 20–25 years. Although errors made by a sleep-deprived resident in a New York City hospital are believed to have caused a patient’s death, few studies have shown a direct link between fatigue and patient safety (Asken and Raham, 1983; Friedman et al., 1971; Parker, 1987; Poulton et al., 1978). The findings of Smith-Coggins and colleagues are typical. Emergency room physicians working at night reported feeling significantly more sluggish, less motivated, and less clear-thinking than when working days. Although, they were able to maintain their accuracy in interpreting 12-lead electrocardiograms (ECGs) and rhythm strips, their reactions times were slower and they took longer to intubate a mannequin when working the night shift (Smith-Coggins et al., 1997). Only a few studies have demonstrated that clinical performance is adversely affected by sleep deprivation. Unlike earlier studies, recent studies have been tightly controlled. Earlier methodological flaws (e.g., tests that were too short or tested factual knowledge, which is relatively insensitive to sleep deprivation; included performance incentives; or, most significantly, failed to control for the residents’ actual sleep schedules prior to and during the studies) (Weigner and Ancoli-Israel, 2002) have been corrected. Researchers no longer expect to find differences between “rested” residents—e.g., those who had more than 4 hours of sleep (Bartle et al., 1988; Deaconson et al., 1988; Light et al., 1989), more than 5 hours of sleep, (Hawkins et al., 1985; Reznick and Folse, 1985), or “regular” sleep (Denisco et al., 1987; Storer et al., 1989), or were not on call (Orton and Gruzelier, 1989)—and “fatigued” residents. They assume all residents have a significant sleep deficit, even those tested when not on call (Weigner and Ancoli-Israel, 2002). Several studies have shown impaired performance on measures of alertness and concentration, standardized tests of creative thought processes, and cognitive performance on a standardized computerized test battery after on-call periods ranging from 24 hours to an entire weekend (Leonard et al., 1998; Nelson et al., 1995; Wesnes et al., 1997). In studies using virtual-reality simulations, surgical residents made more errors and were slower to complete electrocoagulation of bleeding tissue as sleep loss increased
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Keeping Patients Safe: Transforming the Work Environment of Nurses (Taffinder et al., 1998). Moreover, error rates were higher among residents after a night on call than during normal daytime hours (Grantcharov et al., 2001). Realistic patient simulators have also been used to evaluate the performance of anesthesiologists at night when fatigued and during regular workdays (Ou et al., 2001), as well as under conditions of acute sleep deprivation (e.g., awake for 25 hours) or being well rested (2 hours of extra sleep on average for four consecutive nights before the study) (Gaba, 1998; Weigner et al., 1998). Videotapes from the latter study showed sleep-deprived residents actually falling asleep while administering anesthesia. Despite evidence that patient care may be compromised if a fatigued, sleep-deprived clinician is allowed to operate, administer anesthesia, manage a medical crisis, or deal with an unusual or cognitively demanding clinical presentation (Weigner and Ancoli-Israel, 2002), there is significant resistance to limiting the hours worked by resident physicians. Concerns have been expressed about reduced learning opportunities if resident work hours are curtailed (Greenfield, 2001; Holzman and Barnett, 2000; Suk, 2001), as well as decreased professionalism and commitment to patients (Holzman and Barnett, 2000). Current resident work hours have also been defended on economic grounds (Green, 1995; Patton et al., 2001; Thorpe 1990). Only the state of New York limits the hours worked by resident physicians. The “Bell Regulations”4 were enacted following the death of Libby Zion, the 18-year old daughter of Sidney Zion, an attorney and writer for the New York Times, in 1984. Her death triggered an aggressive media campaign questioning the quality of care in teaching hospitals, as well as a grand jury investigation into her death (Asch and Parker, 1988; Kwan and Levy, 2002). Although neither the hospital nor physicians were faulted, the grand jury did find fault with the residency training system and physician staffing patterns that allowed Libby Zion’s death to occur. Five specific factors were identified as contributing to her death: (1) she was not examined by an attending physician with experience in emergency medicine when admitted to the ER in an agitated condition, complaining of fever; (2) after transfer to a medical unit, she was cared for by first- and second-year residents who were largely unsupervised; (3) she was admitted at 2:00 a.m., when both residents caring for her had been at work for 18 straight hours; (4) the first-year resident ordered that she be placed in physical restraints without reevaluating her condition; and (5) she was given meperidine (Demerol) despite the resident’s knowledge that she was also taking phenalzine.5 4 New York State Health Code. The Bell Regulations. N.Y.C.R.R. § 405.4 (1989). 5 Meperidine is contraindicated for a patient taking phanelzine.
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Keeping Patients Safe: Transforming the Work Environment of Nurses In March 1987, the New York State Commissioner of Health appointed an Ad Hoc Advisory Committee on Emergency Services to analyze the grand jury’s findings. The committee, chaired by Dr. Bertand Bell, reviewed the grand jury’s report and issued several recommendations to the New York State Department of Health, including that residents should not work more than 80 hours per week, more than 24 consecutive hours, or more than 6 days without at least one 24-hour period off duty (Holzman and Barnett, 2000; Kwan and Levy, 2002). Rest periods of at least 8 hours between shifts were also mandated (Holzman and Barnett, 2000). ER residents and attending physicians were limited to 12-hour shifts (Kwan and Levy, 2002). The committee’s recommendations were then incorporated into the New York State Code in 1989. Although the New York Hospital Association immediately filed suit contending that the regulations were arbitrary, had been improperly adopted, and failed to provide adequate reimbursement for the increased costs of their implementation,6 its appeal to the State Supreme Court failed (Patton et al., 2001). Also in 1989, the ACGME amended its regulations to require accredited internal medicine residency programs to limit the hours worked by residents. Internal medicine residents could spend no more than 80 hours per week providing patient care, could be on call no more than every third night, and on average would have to have the opportunity to spend at least 1 of every 7 days free of patient care duties (Green, 1995). Today there are 26 sets of different guidelines, each developed by a different Residency Review Committee. Weekly work hour limitations range from “whatever is considered ‘appropriate’ by residency directors” (general surgery) to 72 hours (emergency medicine) (Gurjala et al., 2001; Kwan and Levy, 2002). Not only are the guidelines inconsistent across the various specialties, but they are also voluntary, not mandatory. Neither the Bell Regulations in New York nor the ACGME guidelines have been effective in curtailing the hours worked by resident physicians (Gurjala et al., 2001; Kwan and Levy, 2002). Fully 92 percent of New York hospitals were not complying with the Bell Regulations during 1991–1992, a fact known by the New York State Department of Health (Patton et al., 2001). In a survey conducted almost 10 years after the Bell Regulations were enacted, residents in all New York teaching hospitals reported working an average of 95 hours per week (Anonymous, 1998). In 1998, a surprise investigation conducted by the New York State Department of Health found all 12 hospitals visited to be violating resident work hour limits. Over one-third of the residents (38 percent) had worked in excess of 24 consecutive hours, 37 percent were working more than 85 hours per week, 6 Hospital Association v. Axelrod, 546 N.Y.S.2d 531. 1989.
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