The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review

摘要

Background? Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents still is unclear. Advocates interpret the research as necessitating immediate change; opponents draw competing conclusions.;Objective? This study updates a systematic review of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education's 2011 regulations.;Methods? The review draws on reports catalogued in MEDLINE and PreMEDLINE from 2010 to 2013. Interventions that dealt with the duty hour restrictions included night float, shortened shifts, and protected time for sleep. Outcomes were patient care, resident well-being, and resident education. Studies were excluded if they were not conducted in patient care settings.;Results? Twenty-seven studies met the inclusion criteria. Most frequently, the studies concluded that the restrictions had no impact on patient care (50%) or resident wellness (47%), and had a negative impact on resident education (64%). Night float was the most frequent means of implementing duty hour restrictions, yet it yielded the highest proportion of unfavorable findings.;Conclusions? This updated review, including 27 recent applicable studies, demonstrates that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education. New approaches to the issue of physician fatigue and its relationship to patient care and resident education are needed.;Introduction Despite a large number of primary studies and numerous systematic reviews, the impact of resident duty hour restrictions on patients and residents remains unclear. In turn, reviewers find the impact to be favorable, unfavorable, neither, or inconclusive.1–6 For programs that have implemented these changes, and for those about to, this literature is vexing. From 2004 to 2013, 9 peer-reviewed systematic reviews of the duty hour literature were conducted (table 1).1–9 Eight of the reviews examined the impact of duty hour restrictions on patient safety. A total of 2 reported a positive impact,1,5 2 reported no impact,3,6 and 4 found that the effect differed across studies.2,4,7,9 Five reviews examined the impact on resident well-being, with 4 finding positive changes.1,4,8,9 Resident education is examined in 5 reviews, with 1 concluding the impact is unfavorable,5 2 concluding there is no impact,4,6 and 2 finding that the impact is inconclusive.8,9 Despite these equivocal findings, organizations that represent both patients and residents cite empirical support for action. The Bell Commission, which instituted New York State's limit on resident work hours10; the Institute of Medicine's Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety1; the Accreditation Council for Graduate Medical Education (ACGME)11; the Fédération des médecins résidents du Québec12; and Canada's National Steering Committee on Resident Duty Hours13 all point to the literature in their campaigns to limit duty hours. Others, notably residents,14,15 program directors,16 and other experts,17 read the same body of literature and concluded that restrictions may be detrimental. View larger version (30K) TABLE 1Results of 9 Systematic Reviews of the Impact of Resident Duty Hour Restrictions on 3 Categories of Outcomes;Methods As an update, this review modeled the methodology of the original study, including the search query, data sources, eligibility criteria, study selection and data extraction, assessment of study quality, and data synthesis. Here we present a concise description of the methodology: the full description is available in the original study.5 Our review followed the PRISMA guidelines for systematic reviews.18 Eligibility Criteria,