Spellberg B, Sue D, Chang D, Witt M. Change in Intern Calls at Night After a Work Hour Restriction Process Change. JAMA Intern Med. 2013;173(8):707-709. doi:10.1001/jamainternmed.2013.2968
Author Affiliations: Divisions of General Internal Medicine (Dr Spellberg), Pulmonary and Critical Care Medicine (Drs Sue and Chang), and HIV Medicine (Dr Witt), Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; and David Geffen School of Medicine, University of California, Los Angeles (Drs Spellberg, Sue, Chang, and Witt).
To accommodate shorter intern shifts (16 hours) required by the Accreditation Council for Graduate Medical Education (ACGME), a night-float cross-coverage system was put into place at Harbor–University of California, Los Angeles, Medical Center (HUMC) in July of 2011. We conducted prospective surveys to evaluate the nature and frequency of the calls received by night-float residents.
At HUMC, 5 ward teams, each composed of 2 residents and 3 interns, admit patients to the hospital, with 1 team on call each night. Before the new work hour rules, the overnight on-call interns (3 per night) provided cross-coverage for the other 12 interns who were not on-call. After the change, 1 second-year night-float resident cross-covered for all 12 interns who were not on-call, from 5 PM to 7 AM. We deployed a written survey instrument, on which all calls received by the night-float resident were documented in real-time. This study was deemed as category-2 exempt under 45 CFR 46.101(b) by the John F. Wolff institutional review board at the Los Angeles Biomedical Research Institute.
Data were available from 16 of the 17 evenings during the first survey period (survey response rate, 94%), totaling 547 calls, with a median of 35 (range, 18-57) calls per 14-hour period. The median time between the calls was 11 (range, 5-25) minutes. A total of 128 calls (23%) related to issues that had been signed out by the primary team. By far the most common reason for calls was “provider confusion” (ie, calls for patients for whom a night-float resident was not responsible; Table). The next 2 most common causes of calls (minor patient complaints and order clarifications) also could not have been altered by changes to the sign-out process.
After the first survey, we implemented a new page forwarding system, so that residents leaving the hospital electronically forwarded their pages to the night-float resident. We also altered procedures related to renewing restraints, so health care providers would no longer get called in the middle of the night to renew automatically expiring orders. As a result, during the second period (surveys were completed on 10 of the 14 nights), a significantly lower number of calls were logged (median of 20 [range 18-25] calls per night, P = .003 vs the first period). The median time between the calls was 20 (range, 10-55) minutes, which was significantly longer than in the first survey period (P < .001).
We provide the first description of the reasons for overnight calls to a night-float cross-coverage resident at an internal medicine training program in the United States. Although the intent of the ACGME rules is to enhance sleeping opportunities for interns, the absence of new resources attached to these work hour rules results in increased patient hand-offs and a shift of work from interns to higher-level trainees. In 1993, the initial move toward work hour restrictions was noted to result in increasing patient hand-offs and fragmented care.1 Medical decision making by a cross-covering health care provider after patient hand-off has been shown to result in increased risk of harm to patients.2,3 Indeed, in 1994 Petersen et al2 concluded that even a fatigued intern with detailed knowledge about a patient may be able to provide more appropriate care than a well-rested one who is less familiar with the patient.2 As work hours have been further restricted over the past decade, we have transitioned from the fatigued primary provider to a well-rested cross-covering provider to the current situation, which is a fatigued cross-covering provider. Our results underscore that the increased rest achieved for interns—who are rarely decision makers in patient care issues—is achieved at the expense of both increasing patient hand-offs (and hence increasingly fragmented care) and increasing fatigue for advanced trainees who are more responsible for clinical decision making. Our findings are also concordant with emerging data from surgical literature, indicating that night-float residents are at particular risk for sleep deprivation.4
The majority of the calls in our survey could not have been prevented by improvements in sign-out procedures. Further research is needed to determine if clinical outcomes can be improved by improved sign-out. Until such data are available, it is potentially dangerous to presume that the increased risk to patients that results from increased hand-offs and increased fatigue of higher-level trainees necessitated by the shorter ACGME work hour rules can be mitigated by an as of yet unknown improvement to the sign-out/hand-off process.
In conclusion, we provide the first comprehensive description of overnight calls in an internal medicine training program night-float, cross-coverage system. Our results suggest that decreasing work hours for interns can have unfortunate impact on the workload and restfulness of higher-level trainees who have to “fill the breach.” Additional research is needed to ensure the safety of patients and to optimize the education and patient care experiences of trainees given changing work hour requirements.
Correspondence: Dr Spellberg, Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson St, Liu Vaccine Center, Torrance, CA 90502 (email@example.com).
Published Online: March 25, 2013. doi:10.1001/jamainternmed.2013.2968
Author Contributions:Study concept and design: Spellberg, Chang, and Witt. Acquisition of data: Spellberg and Sue. Analysis and interpretation of data: Spellberg, Chang, Chang, and Witt. Drafting of the manuscript: Spellberg. Critical revision of the manuscript for important intellectual content: Spellberg, Sue, Chang, Chang, and Witt. Statistical analysis: Spellberg. Administrative, technical, and material support: Spellberg, Sue, and Chang. Study supervision: Spellberg, Chang, and Witt.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the residents who completed the surveys for the study. Nikhil Daga, MD, Bradley Messenger, MD, and Allen Kuo, MD, all of Harbor-UCLA Medical Center disseminated and gathered the overnight call surveys. No compensation was received for these study activities.