Cheryl Ulmer, Dianne Miller Wolman, Michael M. E. Johns, Editors Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP233200700003T between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, fnd- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily refect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Resident duty hours : enhancing sleep, supervision, and safety / Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety ; editors, Cheryl Ulmer, Dianne Miller Wolman, Michael M.E. Johns. p. ; cm. Includes bibliographical references and index. ISBN 978-0-309-12776-9 (hardcover) 1. Residents (Medicine)—United States. 2. Fatigue. 3. Sleep deprivation. 4. Hours of labor. 5. Hospitals—United States—Safety measures. 6. Medical errors. I. Ulmer, Cheryl. II. Wolman, Dianne Miller. III. Johns, Michael M. E. IV. Institute of Medicine (U.S.). Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. [DNLM: 1. Internship and Residency—standards—United States—Guideline. 2. Education, Medical, Graduate--standards—United States—Guideline. 3. Medical Errors— prevention & control—United States—Guideline. 4. Patient Care—standards—United States—Guideline. 5. Sleep Deprivation—prevention & control—United States—Guideline. 6. Work Schedule Tolerance—United States—Guideline. W 20 R4335 2009] RA972.R465 2009 610.71’55—dc22 2009003372 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Photo Credit: Front cover reprinted with permission from Emory University Photo/Video, 2008. Suggested citation: IOM (Institute of Medicine). 2009. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press. “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. The National Academy of Sciences is a private, nonproft, self-perpetuating society of distinguished scholars engaged in scientifc and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientifc and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientifc and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org COMMITTEE ON OPTIMIZING GRADUATE MEDICAL TRAINEE (RESIDENT) HOURS AND WORK SCHEDULES TO IMPROVE PATIENT SAFETY MICHAEL M. E. JOHNS (Chair), Chancellor, Emory University, Atlanta, GA JAMES BAGIAN, Chief Patient Safety Offcer, Director, VA National Center for Patient Safety, Department of Veterans Affairs, Ann Arbor, MI JAYANTA BHATTACHARYA, Assistant Professor, Center for Primary Care and Outcomes Research, Stanford University, CA MAUREEN BISOGNANO, Executive Vice President and Chief Operating Offcer (COO), Institute for Healthcare Improvement, Cambridge, MA PASCALE CARAYON, Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, and Director, Center for Quality and Productivity Improvement, University of Wisconsin–Madison JORDAN J. COHEN, Professor, Medicine and Public Health, George Washington University, Washington, DC DAVID F. DINGES, Professor and Chief, Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia JAVIER A. GONZALEZ DEL REY, Professor of Pediatrics and Director, Pediatric Residency Programs, Cincinnati Children’s Hospital Medical Center, Ohio PETER J. KOLESAR, Professor Emeritus and Research Director, Deming Center for Quality, Productivity and Competitiveness, Columbia University, New York, NY BRIAN W. LINDBERG, Executive Director, Consumer Coalition for Quality Health Care, Washington, DC KENNETH M. LUDMERER, Professor of Medicine and Professor of History, Washington University, St. Louis, MO DANIEL MUNOZ, Fellow, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD CHRISTOPHER S. PARSHURAM, Director, Center for Safety Research, Assistant Professor, Department of Critical Care Medicine, Hospital for Sick Children, and Departments of Paediatrics, Health Policy Management and Evaluation, University of Toronto, ON, Canada ANN E. ROGERS, Associate Professor, University of Pennsylvania School of Nursing, Philadelphia DENISE M. ROUSSEAU, H. J. Heinz II Professor of Organizational Behavior and Public Policy and Director, Project of Evidence-Based Organizational Practices, Carnegie Mellon University, Pittsburgh, PA EDUARDO SALAS, Pegasus Professor and University Trustee Chair, Department of Psychology and Institute for Simulation and Training, University of Central Florida, Orlando BRUCE SIEGEL, Director, Center for Health Care Quality, George Washington University School of Public Health and Health Services, Washington, DC v IOM Study Staff Cheryl Ulmer, Study Co-director Dianne Miller Wolman, Study Co-director Michelle Bruno, Research Associate Cassandra Cacace, Senior Program Assistant Roger Herdman, Director, Board on Health Care Services vi Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: BARBARA LEE BASS, Methodist Institute for Technology, Innovation & Education (MITIE)TM, Department of Surgery, The Methodist Hospital, Houston, TX, and Weill Medical College of Cornell University, New York LINDA EMANUEL, Buehler Center on Aging, Health and Society, Feinberg School of Medicine, Northwestern University, Chicago, IL KATHLYN E. FLETCHER, Primary Care Division, Clement J. Zablocki VA Medical Center, Milwaukee, WI DORRIE K. FONTAINE, University of Virginia School of Nursing, Charlottesville, VA ROBERT L. HELMREICH, Human Factors Research Project, The University of Texas at Austin, Austin, TX STEVEN K. HOWARD, VA Palo Alto Health Care System Anesthesia Service and Stanford University School of Medicine Anesthesia Service, Palo Alto, CA vii viii REVIEWERS SANDEEP JAUHAR, Heart Failure Program, Long Island Jewish Medical Center, New York, NY ERIC B. LARSON, Group Health Center for Health Studies, Seattle, WA ARTHUR A. LEVIN, Center for Medical Consumers, New York, NY STEVEN LIPSTEIN, BJC HealthCare, St. Louis, MO ALAN R. NELSON, American College of Physicians, Fairfax, VA TERRANCE D. PEABODY, Section of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Medical Center, Chicago, IL DEBORAH E. POWELL, University of Minnesota Medical School, Minneapolis, MN RANGARAJ RAMANUJAN, Owen Graduate School of Management, Vanderbilt University, Nashville, TN ROGER R. ROSA, National Institute for Occupational Safety and Health, Washington, DC DAVID P. STEVENS, Quality Literature Program, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH KEVIN VOLPP, Center for Health Equity Research and Promotion (CHERP), Philadelphia VA Medical Center, and Center on Health Incentives, Leonard Davis Institute for Health Economics, University of Pennsylvania School of Medicine and the Wharton School, Philadelphia, PA JAMES K. WALSH, Sleep Medicine and Research Center, St. Luke’s Hospital, Chesterfeld, MO Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the fnal draft of the report before its release. The review of this report was overseen by Donald Steinwachs, Health Services Research and Development Center, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hop- kins University, Baltimore, MD, and Adel A. F. Mahmoud, Woodrow Wilson School and Department of Molecular Biology, Princeton Univer- sity, Princeton, NJ. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the fnal content of this report rests entirely with the authoring committee and the institution. Foreword Most physicians can recall moments of total exhaustion during their residency, when they had been working steadily on patients around the clock, and other moments of total exhilaration, such as when they realized a critically ill patient would pull through. The intense residency learn- ing period that follows medical school is an integral part of a physician’s professional development and essential preparation for clinical practice. Physicians may have very strong feelings about how well our own training experience prepared us and ways in which it could have been improved. We may have memories of mistakes we made during training and wonder whether they could have been prevented had we consulted the attending earlier, received more information during the handover, remembered a criti- cal test, or correctly calculated the dose of medication. Today, with deeper appreciation of risks to patients, we may wonder how the work environ- ment of residents can be redesigned to enhance patient safety and whether this can be done while preserving or, even better, while enhancing the learn- ing to be a doctor that is at the heart of any residency training program. The Institute of Medicine (IOM) appointed the Committee on Opti- mizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, at the request of Congress and the Agency for Healthcare Research and Quality, to weigh these questions. Specifcally, the committee examined whether residents’ duty hours and schedules could be improved to reduce sleep deprivation, performance degradation, and the risk of error, while ensuring that residents have suffcient time to receive the necessary training and experience. The IOM has a history of reports on medical education, training, and the healthcare workforce, as well as ix