The dan­gers of sleepy work­ers

Joint Com­mis­sion high­lights dan­gers, of­fers so­lu­tions

Modern Healthcare - - FRONT PAGE - Mau­reen McK­in­ney

Sleep medicine ex­perts and pa­tientsafety ad­vo­cates are ap­plaud­ing the Joint Com­mis­sion’s re­cently is­sued sen­tinel event alert, which high­lights the haz­ards of health­care worker fa­tigue and of­fers strate­gies to mit­i­gate it.

“The first and most im­por­tant step is rais­ing provider aware­ness on this is­sue,” said Dr. Christo­pher Lan­dri­gan, di­rec­tor of the Sleep and Pa­tient Safety Pro­gram at 773-bed Brigham and Women’s Hos­pi­tal, Bos­ton, and re­search di­rec­tor of in­pa­tient pe­di­atrics ser­vices at 396-bed Chil­dren’s Hos­pi­tal Bos­ton. “There are still a large num­ber of health­care providers that don’t know about the lit­er­a­ture show­ing that fa­tigue hurts per­for­mance.”

Lan­dri­gan has au­thored stud­ies ex­am­in­ing the dan­ger­ous ef­fects of long work hours. In a 2004 study that ap­peared in the New Eng­land Jour­nal of Medicine, Lan­dri­gan and col­leagues found that in­terns in in­ten­sive-care units who worked 30-hour shifts on a reg­u­lar ba­sis made five times as many di­ag­nos­tic er­rors and 36% more se­ri­ous med­i­cal er­rors as those who worked no more than 16 con­sec­u­tive hours at a time.

In the alert, re­leased Dec. 14, the Joint Com­mis­sion listed nine ev­i­dence-based steps providers can take to lower the risk of harm, in­clud­ing re­design­ing work sched­ules, ed­u­cat­ing staff about the dan­gers of long hours and en­cour­ag­ing a cul­ture of safety.

“That means ev­ery­one has a voice and can com­mu­ni­cate ef­fec­tively,” ex­plained Ana Pu­jols Mc­kee, the Joint Com­mis­sion’s chief med­i­cal of­fi­cer. “If any mem­ber of the team sees an er­ror or some­thing that has been over­looked, they can speak up.”

The alert also em­pha­sized the im­por­tance of tran­si­tions of care, when re­spon­si­bil­ity for the care of a pa­tient is trans­ferred from one care­giver to an­other. “Since pa­tient hand­offs are a time of high risk—es­pe­cially for fa­tigued staff—as­sess your or­ga­ni­za­tion’s hand­off pro­cesses and pro­ce­dures to en­sure that they ad­e­quately pro­tect pa­tients,” the alert said.

The Joint Com­mis­sion’s alert is only the lat­est in a se­ries of re­cent ef­forts to draw at­ten­tion to the is­sue of fa­tigue-re­lated safety risks. In June 2010, 26 ex­perts in medicine, sleep sci­ence and pa­tient safety gath­ered at a con­fer­ence at Har­vard Med­i­cal School to dis­cuss ways to im­ple­ment the In­sti­tute of Medicine’s 2009 rec­om­men­da­tions for res­i­dent work hours.

The re­sults of that con­fer­ence were pub- lished in a June 2011 white pa­per, which in­cluded guid­ance on im­pos­ing work-hour lim­its and re­design­ing the hand­off process.

And in July, new work-hour re­stric­tions and su­per­vi­sory re­quire­ments from the Ac­cred­i­ta­tion Coun­cil for Grad­u­ate Med­i­cal Ed­u­ca­tion went into ef­fect, man­dat­ing that ju­nior res­i­dents work no more than 16 hours at a time.

But those stan­dards don’t ap­ply to other health­care work­ers, said Lan­dri­gan, one of the au­thors of the June white pa­per.

“Although things have changed for the most ju­nior of doc­tors, other physi­cians are still al­lowed to work up to 28 hours at a time, and nurses have no lim­its,” he said. “That’s in stark con­trast to other in­dus­tries that have taken this is­sue much more se­ri­ously and put more safe­guards in place.”

Ann Rogers, a sleep medicine ex­pert and fac­ulty mem­ber at Emory Univer­sity Nell Hodg­son Woodruff School of Nurs­ing, At­lanta, who worked with the Joint Com­mis­sion on the alert, echoed Lan­dri­gan’s con­cerns about other health­care work­ers. Rogers coau­thored a 2004 study that found that nurses who worked shifts of 12 hours or longer were three times as likely to make er­rors.

Chang­ing nurses’ work sched­ules isn’t easy, Rogers says, be­cause so many hos­pi­tals are al­ready short-staffed and be­cause many nurses fa­vor work­ing fewer but longer shifts, or pick­ing up over­time.

“It’s a dif­fi­cult process,” Rogers said. “Nurses have to pro­vide 24-hour care to their pa­tients and there are of­ten not enough staff.”

De­spite the bar­ri­ers to change, the Joint Com­mis­sion’s de­ci­sion to in­clude the alert nurses, phar­ma­cists and other health­care pro­fes­sion­als who of­ten work ex­tended hours was a wel­come one, said Linda Scott, as­so­ci­ate dean of Grand Val­ley State Univer­sity’s Kirkhof School of Nurs­ing, Al­len­dale, Mich.

“I was very ex­cited to see the alert come out,” said Scott, who co-au­thored with Rogers the 2004 study on nurse-staffing hours and med­i­cal er­rors. “I’m hope­ful it will set the stage for us to use ev­i­dence to im­ple­ment fa­tigue-man­age­ment strate­gies be­cause we need a vig­i­lant work­force and we need to pro­tect our pa­tients.”

And that may re­quire a sig­nif­i­cant change in hos­pi­tal poli­cies, ex­tend­ing all the way to or­ga­ni­za­tions’ hu­man­re­sources de­part­ments, she added. For in­stance, nurses caught nap­ping are usu­ally dis­ci­plined or fired, Scott said. In­stead, she con­tends that hos­pi­tals should ac­knowl­edge the prob­a­ble need for a nap dur­ing a long shift and they should make con­ces­sions for it.

“It’s not just nurses’ re­spon­si­bil­ity to come to work alert,” Scott said. “Hos­pi­tals need to part­ner with their em­ploy­ees and un­der­stand that they may need to pro­vide the op­por­tu­nity to sleep. It’s chang­ing the mind­set from the old sta­tus quo to what is bet­ter and safer for ev­ery­one.”

Res­i­dents, too, are of­ten re­luc­tant to work fewer hours be­cause of fears of miss­ing im­por­tant on-the-job train­ing op­por­tu­ni­ties, Lan­dri­gan said.

“Five or 10 years ago, there was de­nial that fa­tigue even af­fected per­for­mance at all,” he said. “Now there is a greater ac­cep­tance that it’s an is­sue, but there are con­cerns about prac­ti­cal prob­lems, like com­mu­ni­ca­tion and ed­u­ca­tion. In my view, these are sur­mount­able, and if we are se­ri­ous about safety, we have to do it.”


Re­design­ing work sched­ules is one strat­egy cited in the alert to re­lieve fa­tigued health­care work­ers.

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