Sleepless in New Haven

February 05, 2017

Hi everyone,

Twenty-eight hour calls make no sense, until you consider the alternative. As a veteran of long shifts, I have strong opinions about the impact of call on continuity of care, sleep, and trainee exploitation.

First, regarding exploitation: by definition, extended shifts advantage hospitals economically because they would otherwise have to hire more physicians and extenders. In fact, this has already happened: residencies are larger than before, and extenders now perform roles previously limited to physicians. We can’t ignore the reality that further limitations would be costly, or force residencies to curtail electives. I don’t believe hospitals intentionally exploit trainees, which is a loaded notion, but the economic realities are clear.

It would be a mistake, though, to assume extended shifts have entirely economic justifications. The very notion of a "resident" reflects a bygone era when trainees lived in the hospital and were essentially always on duty. Expectations were less heroic then. Patients were less sick and spent long periods in the hospital convalescing or awaiting tests. Once during my residency, I cared for an elderly lady who developed a cough in house. My attending told us since she didn’t have a cough on admission, we couldn’t discharge her until it resolved. With fewer sick patients, my colleagues and I managed 3-4 hours of sleep on most nights. On some nights we didn’t sleep, but that was rare.

Call became steadily more difficult after my residency. Patients went home sooner and those remaining hospitalized were sicker and needed much more attention. Length of stay shortened and trainees spent more time admitting and discharging patients. When I was a resident, the notion of “evidence-based medicine” was in its infancy. Less evidence meant fewer mistakes, so we were less likely to get grilled on antibiotic choices or ventilator settings. The advent of the patient safety movement, for all its benefits, also created work. When I was a resident, if a patient didn’t know her medications, I could just list them as “unknown.” Nowadays—and appropriately so—we call pharmacies to perform medicine reconciliation, which takes time.

An explosion in documentation probably contributes most to the growing workload. Documentation requirements were much less extensive when I was an intern. For example, sometimes I could write a progress note like this:

S- Feeling better on antibiotics

O- VSS, afebrile, exam unchanged

A- Patient improving

P- Continue current management

Mark D. Siegel, MD

PGY1

We could easily save time today by streamlining our notes, but even if we make our notes more concise, documentation will still contribute significantly to intern work.

By 2011, the workload made it nearly impossible for interns to sleep on overnight shifts. In this context, the ACGME decided to eliminate overnight call for interns, with the assumption being that both interns and patients would benefit. It soon became apparent, however, that the new rules introduced their own problems. First, because overall workload didn’t change, interns began to experience stress from work compression, trying to finish the same amount of work in less time. As a result, they were forced to choose between adhering to work hour limits while leaving their work incomplete vs. finishing their work but violating duty hours. Second, the introduction of distinct day and night teams increased the number of handoffs, creating new safety concerns. Third, the impact on education was mixed. While rested trainees undoubtedly retained more information at teaching sessions, this was offset by less experiential learning. In the MICU, interns missed countless opportunities to manage ARDS and septic shock patients during the most dynamic portion of their illnesses. On the floor, because most patients were admitted during the evening, day interns admitted few of their own patients.

Given the uncertainty about the value of overnight call, we were pleased to participate in the iCOMPARE study, which was designed to compare 28 hour calls to day-night shifts. Our residency was randomized to the study’s overnight arm, so we re-introduced overnight call in the MICU and on Fitkin and Generalist. Although the results remain unknown, I doubt iCOMPARE will show educational or safety differences between the groups. When the study ended, we considered whether to continue with 28 hour call and, after extensive meetings with trainees and faculty, we decided to continue call in the MICU and on Fitkin.

To continue overnight call , we had to adhere to two stipulations. First, the ACGME mandates viewing 28 hour call as a 24+4 shift: 24 hours of patient care followed by 4 hours of transition. In other words, the last 4 hours are not to be used to complete tasks, perform procedures, call consults, or write notes. Teaching is not explicitly addressed, but clearly should not be viewed as required (i.e., the rules do not explicitly prohibit teaching, particularly when transitioning care to the day team). We are also obligated to give overnight interns the opportunity to nap. It’s self-evident that our adherence to these stipulations is inconsistent, particularly because of note writing. Although duty hour reports suggest it doesn’t happen most of the time, more than a few interns stay past 28 hours to finish notes. More troubling, few interns sleep overnight because they’re writing notes.

To the extent that 28 hour call has value, we can only continue it if we ensure interns leave on time and get meaningful opportunities to sleep. They should never be forced to make the impossible choice between sleeping and working. For this reason, as discussed in last Friday's Program Director's meeting and in the Chief's most recent Chief on Call announcement, we are going to institute the following:

1.Interns on overnight call will no longer be expected to write progress notes or post-call addenda

2.We strongly encourage residents to hold their interns’ pagers for at least 2 hours during an overnight call so they get the opportunity to sleep. Hopefully by eliminating post call addenda and progress notes (which make no sense to write in the middle of the night anyway), we will open a window of opportunity for interns to lay down

3.We also strongly encourage residents on overnight calls to find time to sleep. At this point in the year, interns should be able to spend time on the floor working independently, knowing they can wake their resident if needed. In the MICU, interns can seek support from the overnight attendings.

4.The Chiefs will be working with interested housestaff to design efficiencies such as “dot phrases” to facilitate the task for day teams that assume note-writing responsibilities. The key will be to ensure this task is manageable- meeting our documentation needs without creating an undue burden for the day teams.

For the last few years, we’ve toggled back and forth between eliminating and resuming overnight call. Both systems have advantages and disadvantages, with the disadvantages always seeming more compelling for the system currently in use. For example, before we switched to overnight call, interns worried they were not being prepared adequately for residency and favored switching to overnight call. In contrast and understandably, fatigue has now become the chief concern. For this reason, it I think we should try tweaking overnight call to see if we can make it function better and achieve important training goals. However, we can only justify overnight call if the interns get sleep and leave the hospital on time. A key first step, without question, will be to reduce the documentation burden.

I deeply appreciate the input I’ve gotten from the interns and others on the Executive Council, as well as multiple additional housestaff who have weighed in on this issue. I look forward to further discussion and input. Please contact me with questions or concerns.

Enjoy the super bowl if you have the evening off!

Warmly,

Mark

Submitted by Mark David Siegel on February 05, 2017