提示: 手机请竖屏浏览!

住院医师非24小时值班制对患者安全的影响
Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts


Christopher P. Landrigan ... 其他 • 2020.06.25
相关阅读
• 住院医师灵活和标准值班时间规则下的患者安全性结局

摘要


背景

取消住院医师的长时间值班对患者安全的影响仍存在争议。

 

方法

我们开展了一项多中心、整群随机、交叉试验,本试验纳入在重症监护病房(ICU)轮转的儿科住院医师,比较了以下两种值班制:包含≥24小时班次的长时间值班制(对照值班制),以及取消长时间值班,住院医师交替上≤16小时的日班和夜班的值班制(干预值班制)。主要结局是住院医师所犯的严重医疗错误,我们通过密集监测(包括直接观察和病历审核)的方式进行评估。

 

结果

采用两种值班制期间的ICU患者特征相似,但干预值班制期间的住院医师工作量(定义为每名住院医师管理的ICU患者平均数量[±SD])超过对照值班制期间(8.8±2.8 vs. 6.7±2.2)。住院医师在干预值班制期间所犯的严重错误超过对照值班制期间(97.0/1,000患者-日vs. 79.1/1,000患者-日;相对危险度,1.53;95%置信区间[CI],1.37~1.72;P<0.001)。在干预值班制期间,病房范围内的严重错误数量也较多(181.3/1,000患者-日vs. 131.5/1,000患者-日;相对危险度,1.56;95% CI,1.43~1.71)。但不同研究中心之间有较大差异;在一个研究中心,干预值班制期间的错误发生率低于对照值班制期间;在两个研究中心,两种值班制期间的错误发生率相似;在三个研究中心,干预值班制期间的错误发生率高于对照值班制期间。在针对潜在混杂因素(每名住院医师管理的患者数量)进行校正的次要分析中,干预值班制不再与错误增多相关。

 

结论

与我们的假设相反,被随机分配到非长时间值班制的住院医师所犯的严重错误超过被分配到长时间值班制的住院医师,但不同研究中心观察到的影响有差异。在取消长时间值班的值班制中,每位住院医师管理的ICU患者数量较多(由美国国立心肺和血液研究所[National Heart,Lung,and Blood Institute]资助,ROSTERS在ClinicalTrials.gov注册号为NCT02134847)。





作者信息

Christopher P. Landrigan, M.D., M.P.H., Shadab A. Rahman, Ph.D., M.P.H, Jason P. Sullivan, B.S., Eric Vittinghoff, Ph.D., Laura K. Barger, Ph.D., Amy L. Sanderson, M.D., Kenneth P. Wright, Jr., Ph.D., Conor S. O’Brien, B.A., Salim Qadri, B.S., Melissa A. St. Hilaire, Ph.D., Ann C. Halbower, M.D., Jeffrey L. Segar, M.D., John K. McGuire, M.D., Michael V. Vitiello, Ph.D., Horacio O. de la Iglesia, Ph.D., Sue E. Poynter, M.D., M.Ed., Pearl L. Yu, M.D., Phyllis C. Zee, M.D., Ph.D., Steven W. Lockley, Ph.D., Katie L. Stone, Ph.D., and Charles A. Czeisler, M.D., Ph.D. for the ROSTERS Study Group*
From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children’s Hospital — all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children’s Hospital, Iowa City (J.L.S.); Seattle Children’s Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children’s Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.). Address reprint requests to Dr. Landrigan at the Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, or at christopher.landrigan@childrens.harvard.edu. *A list of the members of the ROSTERS Study Group is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med 1971;285:201-203.

2. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005;28:1392-1402.

3. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ 2001;323:1222-1223.

4. Eastridge BJ, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003;186:169-174.

5. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:1249-1255.

6. Veasey S, Rosen R, Barzansky B, Rosen I, Owens J. Sleep loss and fatigue in residency training: a reappraisal. JAMA 2002;288:1116-1124.

7. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA 2002;287:955-957.

8. Samkoff JS, Jacques CH. A review of studies concerning effects of sleep deprivation and fatigue on residents’ performance. Acad Med 1991;66:687-693.

9. Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep 1996;19:318-326.

10. Buysse DJ, Barzansky B, Dinges D, et al. Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care. Sleep 2003;26:218-225.

11. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-1848.

12. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352:125-134.

13. Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med 2004;351:1829-1837.

14. Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. Washington, DC: National Academies Press, 2009.

15. Accreditation Council for Graduate Medical Education. Common program requirements — effective: July 1, 2011 (https://www.acgme.org/Portals/0/PDFs/Common_Program_Requirements_07012011[2].pdf. opens in new tab).

16. Accreditation Council for Graduate Medical Education. Common program requirements — effective: July 1, 2017 (https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. opens in new tab).

17. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med 2016;374:713-727.

18. Silber JH, Bellini LM, Shea JA, et al. Patient safety outcomes under flexible and standard resident duty-hour rules. N Engl J Med 2019;380:905-914.

19. Landrigan CP, Czeisler CA. Patient safety under flexible and standard duty-hour rules. N Engl J Med 2019;380:2379-2380.

20. Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and “accidents.” Am J Ind Med 2006;49:953-963.

21. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-872.

22. Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 1982;56:456-461.

23. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.

24. Chua KP, Gordon MB, Sectish T, Landrigan CP. Effects of a night-team system on resident sleep and work hours. Pediatrics 2011;128:1142-1147.

25. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med 2011;364:1037-1045.

26. Rahman SA, Sullivan JP, Barger LK, et al. Effect on neurobehavioral performance of eliminating extended duration work shifts and implementing a rapidly cycling work roster in the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). Presented at SLEEP 2019, June 8–12, 2019. abstract.

27. Barger LK, Sullivan JP, Blackwell T, et al. Effects on resident work hours, sleep duration, and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). Sleep 2019;42(8):zsz110-zsz110.

28. Blackwell T, Kriesel DR, Vittinghoff E, et al. Design and recruitment of the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study. Contemp Clin Trials 2019;80:22-33.

29. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005;33:1694-1700.

30. Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Costs of adverse events in intensive care units. Crit Care Med 2007;35:2479-2483.

31. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10:199-205.

32. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-1316.

33. Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371:1803-1812.

34. Khan A, Coffey M, Litterer KP, et al. Families as partners in hospital error and adverse event surveillance. JAMA Pediatr 2017;171:372-381.

35. Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of children with multiple chronic conditions to pediatric hospitalizations in the United States: a retrospective cohort analysis. Hosp Pediatr 2017;7:365-372.

36. Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep 2010;33:1043-1053.

37. Gershengorn HB, Harrison DA, Garland A, Wilcox ME, Rowan KM, Wunsch H. Association of intensive care unit patient-to-intensivist ratios with hospital mortality. JAMA Intern Med 2017;177:388-396.

38. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res 2010;45:904-921.

服务条款 | 隐私政策 | 联系我们