Effect of Restrictions on Health Worker Work Hours on Patient Safety - Research Paper Example

?Running Head: EFFECTS OF RESTRICTING HEALTH WORKER WORK HOURS The Effect of Restrictions on Health Worker Work Hours on Patient Safety of Student] [Name of Institution] Introduction In March 5, 1984, Libby Zion, an 18-year old freshman died as a result of the side effects of a medication, which was prescribed late in the night by a resident physician. This marked the origin of the current work hour restrictions and the resultant debates regarding health worker work hour restrictions and their effects on patient safety, health, and outcome improvement. Since, the father to the victim was a New York Times journalist; Zion’s case received considerable media coverage and public attention, culminating in the development of Section 405 of the New York Public Health Code. In 1989, this section required that no residents should work for more than 80 hours a week or 24 hours a shift. In addition, attending physicians were required to be physically available on-site throughout their shifts (Brennan & Zinner, 2003). It is this Section 405 of the New York Health Code, which the Accreditation Council for Graduate Medical Education (ACGME) partly used in the development of health worker work hour guidelines in 2002, a work hour restriction that would later be implemented at the national level in the United States (Brennan & Zinner, 2003). Following the inception and the implementation of work hour rules and restrictions, several researches have been done to determine the nature and extent of these restrictions’ impacts. Although the restrictions were initially intended to protect patients from fatal and non-fatal medical errors, the success of the restrictions remains a hotly debated issue. While the proponents of work hour restrictions have consistently argued that the restrictions have been useful in protecting patients from dangerously overworked and fatigued medical professionals, the opponents are of the opinion that many handoffs, during which health workers hand over patients to their colleagues have considerably impinged on patient safety (Johnson et al., 2005). Moreover, the employment of mid-level health providers and less training time for residents are quite detrimental to patient safety. Thus, despite the myriad studies targeting the efficiency of health worker work hour restrictions and their implications on patient safety, health, and outcome improvements, there have been little systematic reviews and evidences to supporting the early effects of these restrictions (Johnson et al., 2005). The objective of this paper is thus to explore and assess the effects of health worker work hour restrictions on patients’ health and safety, which may be measured in terms of serious medical errors, medical complications, and mortality. In particular, the paper reviews the available literatures on the work hour restriction, the scope and the nature of the issue, and its professional and legal implications. Additionally, the paper gives certain recommendations for the stakeholders to consider implementing. Literature Review To have an idea of the scope of the subject of work hour restrictions and their impacts on patient safety and health, an extensive literature review is in order. A lot of literary materials such as books, journals, and on-line articles have covered the subject of health worker work hour restrictions. While most literatures portray the restrictions in a rather positive light, others report that patients are much less safe compared to the period before the introduction of restrictions on health worker work hours. As revealed during the review, continuity limitations and service collapse brought about by work hour restrictions have been the major causes of concern for the opponents of work hour restrictions. Foresman (2005), mentions that a ‘grey market’ of doctors who are willing to break legislations to observe the restrictions and maintain patient care have taken over the running of health care services in many regions of the world. In literatures written by surgeons and other health care professionals, the opinion that the quality of services provided in health facilities have deteriorated since the introduction of the health worker work hour restrictions by federal and state laws and professional bodies is quite common. In fact, Ferguson et al. (2006) suggest that compliance with these laws and regulations have been largely attained at the expense of patient safety. Moreover, many health facilities and organizations have been found to be lacking in the necessary arrangements and structures to ensure compliance with most work hour restrictions. This lack of arrangements and structures makes activities and processes such as handovers rather inadequate, with some literatures reporting that most health facilities are not truly compliant to the work hour restrictions. Reportedly, some health care workers even go beyond the weekly and daily hour limits. In fact, health facilities and professionals are apparently acting up to cover tasks that others performed before them. In addition, other professionals have been reported to cover roster gaps in other areas of health care to ensure services remain running. Literatures have similarly blamed many shift changeovers for the increased risk of error, danger, and death to which patients are exposed. According to Johnson et al. (2005), restrictions have also affected trainees who have to stay unpaid after their hour limits since they have to see their patients get through care and to gain training opportunities in areas not covered under their restricted/formal hours. There is thus an emerging and existing ‘grey market’ in hospitals, implying that workers’ true work hours are kept off the records (Johnson et al., 2005). Despite the wide literary coverage, problems and debates about work hour restrictions abound, implying the scope of problems related to this subject is rather wide and needs urgent addressing. The Scope of the Problem To ensure patient safety and to minimize the probability of health-adverse events occurring, health workers require being alert so that any changes in patients’ conditions are immediately observed and reacted to. In addition, health workers need to be alert at all times to perform the right clinical and medical assessments accurately and timely and to respond appropriately to patients’ needs. To ensure health workers’ vigilance, it has become necessary that a lot of researches be carried out on the relationship between health worker work hours, their alertness or vigilance and patient safety. Importantly, most health worker work hour studies have largely sought to understand their work patterns and the interconnection between work hours and the probability of medical errors or malpractices (Johnson et al., 2005). Identified as one of the leading causes of mortality, not only in the United States but also in other parts of the world are medical injuries. For example, the Institute of Medicine discovered in a 2000 study that about 98,000 deaths occurred yearly due to avoidable medical errors. Similar results, though not exactly identical, have been established by more recent researches, most of which have indicated that more than 13% of in-patients suffer adverse medical events/harms, 44% of which are preventable in different regions of the world (Shetty & Bhattacharya, 2007). Besides, the deaths that result from medical negligence and errors, there are other monitory costs, which have been found to range in hundreds of millions of U.S dollars in a month. Among the factors cited to contribute to these medical errors, the financial costs, and the deaths is long working hours for health workers, particularly resident physicians. In fact, it is quite a common occurrence to find resident physicians and nurses working for as long as 100 hours a week. Besides fatigue and work-related stress, questions have been raised regarding decision-making by such fatigued and stressed health workers. Nonetheless, the claims relating these deaths to work hours have been challenged by the opponents of work hour restrictions. Because of the complex and controversies surrounding the issue of work hour restrictions and their regulations, health professionals and facilities are faced with myriad legal and professional implications (Foresman, 2005). Legal Implications of Work Hour Restrictions In the United States, medical care is majorly regulated by states through professional organizations and state laws. The same mode of regulation applies to health worker working hours. For instance, in New York, professional organizations such as the Accreditation Council for Graduate Medical Education (ACGME) sets working hours requirements for residency and internship programs. For an illustration, ACGME reduced the number of hours for resident physicians to 80 per week/on average for a four-week period in 2003. Just like New York, other states in the U.S have similar regulations on health worker working hours although most states have adopted the ACGME recommendations. Generally, medical residencies require that their trainees work for lengthy hours, a practice that the public has considered rather harmful, resulting in sleep deprivation. Similarly, the medical education establishment has also decried this trend, describing it as error-prone. In fact, the Accreditation Council for Graduate Medical Education (ACGME) has even carried out a research on the effects of such long working hours and sleep deprivation on intensive care unit healthcare workers. It is after the research that ACGME reduced the work-hours to a maximum of 80 hours per week while setting the overnight call frequency to a maximum of one overnight call in three days (Shetty & Bhattacharya, 2007). In addition, a thirty-hour maximum straight shift with a 10-hour off between shifts has been recommended. Although these limits by ACGME are voluntary, they must be adhered to for a health facility or organization to be accredited. Building upon the recommendations of ACGME is the Institute of Medicine, which kept ACGME’s proposal on the 80-hour a week average for four weeks but recommended that duty hours should never exceed 16 hours per shift, more so for interns. Besides these recommendations by professional organizations, regulatory and legislative attempts at limiting healthcare worker work hours have been forthcoming in recent times. In fact, the role of class action, more so by the more than 200,000 medical residents cannot be overemphasized. In fact, there has been a call by the American Medical Association for the re-evaluation of the training process for residents and interns. However, such activities by professional bodies have been rejected by the U.S. Occupational Safety and Health Administration (OSHA), which prefers the ACGME recommendations. Regardless of the recommendations put forward by the many professional organizations, long healthcare work hours have been blamed on the absence of alternatives for health workers who must accept the terms and conditions of the employments offered. Besides the long working hours, poor supervision has also been blamed for medical errors, negligence, and other medical malpractices (Winslow et al., 2004). Alternative View Although most researches have linked health worker work hour restrictions to poor patient health and medical errors, other systematic evaluations of the effectiveness of health worker work hour restrictions have reported improved patient care. It should be realized that such studies are however not consistent, depending on the measures used, thus providing no statistically significant evidences that patient outcomes would improve as a result of restricting health worker work hours (Winslow et al., 2004). It is also evident in these studies that bio-psychological and experimental results suggest a positive relationship between diminished performance by health workers and fatigue. Nevertheless, patient outcomes have also been shown to be influenced by continuity of care (Winslow et al., 2004). In fact, the benefits accruing from reduced fatigue are somewhat offset by the disruptions caused by reduced/shortened shifts. Therefore, these researches do not make conclusions on the effectiveness of the various laws and regulations that seek to restrict health worker work hours as strategies for improving patient safety and outcomes. In other words, there are no sufficient evidences to support the notion that health worker work hour restrictions negatively affect patient health, safety, and outcome. In fact, short work hours, as required by several healthcare laws and regulations, have been associated in many studies, with loss or lack of continuity of health care for patients. Most affected by this loss of continuity are surgical patients that are increasingly exposed to risks of unpleasant surgical outcomes. Impact on Health Care Policy Health worker work hour restrictions have many implications on the immediate health care policies and legal issues at the local, national and international levels. In fact, while the affairs of work hour restrictions and associated legislations have particularly aimed at making patients safer and healthier, the reality on the ground is that patients have become less safe. Thus the local, national, and international community should formulate, implement, evaluate, and reform health worker work hour policies that promote care continuity, teamwork, and eliminate unnecessary closure of health services resulting from work hour restriction practices (Ferguson et al., 2006). Policies and work hour practices that rely on the use of trainees to meet work hour restrictions should be abolished. In fact, while most governments and health agencies publicly moralize in the fear that trainees are being used in health facilities, it is the same agencies’ and governments’ policies and restrictions, which promote the use of trainees in health facilities. In fact, policies that promote the use of these trainees as locums to cover for dead-end shifts should be abolished. Instead, enough health workers such as doctors, nurses, and surgeons should be recruited and workable rosters drawn to prevent exhausted health workers from dropping out of the workforce (Winslow et al., 2004). These recommendations are not only appropriate or applicable to health providers but also to the national and state legislative organs. Senates, Parliaments, and Congresses should enact effective laws and regulations that would ensure that more health workers are employed and not overworked at the same time. That is, while it is not advisable to interrupt the continuity of health workers, it is important that mechanisms such as legislations are put in place to ensure health care providers receive sufficient rest and relaxation when not on duty. Therefore, ideal legislations and working systems should be developed and implemented to promote quality and safe patient care, create a healthy work-life balance, and offer ample training for health care workers (Glomsaker & Soreide, 2009). Recommendations and Conclusion The need to address the continuity of health care has been made dire by the fact that patients have become more complex in recent times. Second, the restrictions on health worker work hours and the need for balanced work/life lifestyles for health workers have compounded the continuity problems. To ensure care continuity, certain handover styles and practices are recommended. First, a team approach in which hospital-based groups share all patient care or on-call duties is highly suggested. ‘Acute care’ teams would be particularly appropriate and useful in ensuring efficiency during handovers in which services are coordinated to maintain patient stability (Ferguson et al., 2006). Such handovers do not only link patients’ current care to the current but also to the future care. The use of written or verbal communication in signing over patients, rather flawed approaches should also be discouraged in health facilities, more so in team-based patient care or management. In this regard, web-based systems have been preferred as means of improving resident communication and efficiency. Although restrictions on work hours continue to invite debates, it is apparent that fatigue-related errors are just a few of the many challenges that the health industry faces that need to be improved (Ferguson et al., 2006). New rules and laws that would ensure health facilities and professionals think and act creatively to improve patient safety using programs and strategies that are not related to work hours should therefore be established. References Brennan, T. A., and Zinner, M. J. (2003). Residents’ Work Hours: A Wake up Call. International Journal of Quality Health Care, 151(1): 107. Ferguson, C. M. et al. (2006). The Impact of the 80-Hour Resident Workweek on Surgical Residents and Attending Surgeons. Ann Surgery, 243: 871. Foresman, B. H. (2005). Resident-Physicians' Duty Hours: Perceptions and Cultural Expectations in Medicine. Journal of American Osteopath Association, 105: 305–6. Glomsaker, T. B., and Soreide, K. (2009). Surgical Training and Working Time Restriction. British Journal of Surgery, 96(2): 329. Johnson, J. et al. (2005). Communication Failures in Patients Sign-Out and Suggestions for Improvement: A Critical Incident Analysis. Quality and Safe Health Care, 14(1): 407. Shetty, K. D., and Bhattacharya, J. (2007). Changes in Hospital Mortality Associated With Residency Work-Hour Regulations. Ann Intern Medicine, 147: 80. Winslow, E. R. et al. (2004). Has the 80-Hour Work Week Increased Faculty Hours? Current Surgery, 61: 608. Read More