Effects of Sleep Deprivation on Fire Fighters and EMS ... - NAEMT

<strong>Effects</strong> <strong>of</strong> <strong>Sleep</strong> <strong>Deprivation</strong> on Fire Fighters and EMS Responders
Section 3: Postgraduate Medical Training and <strong>Sleep</strong> <strong>Deprivation</strong>
3.1 A Case Study in Mandated Reform: Emotions and an Adverse Event
Medical interns and residents have traditionally worked
long hours, <strong>of</strong>ten spending every third or fourth night in
the hospital, with minimal sleep during those times. Prior
studies suggested that these long work hours impaired
physicians’ performance. Concerns were voiced that sleepdeprived
interns, residents and other physicians working
long hours were prone to errors when performing repetitive
tasks and activities that required sustained vigilance
(Samk<strong>of</strong>f & Jacques, 1991; Lingenfelser et al., 1994;
Taffinder et al., 1998; Veasey et al., 2002). Importantly,
some thought that the performance deficits associated with
long hours could result in patient harm (Leape, Berwick &
Bates, 2002). In addition to potentially hurting patients, these
work patterns possibly were damaging physicians’ health
and well being (Shanafelt et al., 2002; Clever, 2002).
Despite those concerns, the system remained in place until
a highly publicized adverse patient outcome led to legal
actions (Brensilver, Smith & Lyttle, 1998) and public
demand for reform (Kohn, Corrigan & Donaldson, 1999;
Nagourney, 2003). A description <strong>of</strong> the Libby Zion case
and the resultant book detailing its events is presented on page 43.
Following medical school
graduation, M.D.s and D.O.s must
complete a one year internship
before being licensed to practice
medicine. Most then become
residents and spend two to six years
in an accredited program to become
board certified family medicine
physicians, internists, surgeons,
obstetrician/gynecologists,
radiologists, pathologists or one <strong>of</strong>
the many other medical fields. Some
receive additional fellowship training
following residency. Interns and
residents are collectively known as
housestaff or house <strong>of</strong>ficers. The term
is a holdover from when they literally
lived in the hospital or house
throughout their training.
At the insistence <strong>of</strong> the consumer watch group Public Citizen and with the involvement <strong>of</strong> the
Occupational Health and Safety Administration (Gurjala et al., 2001; Pubic Citizen Health Research
Group, 2003), reform was initiated by the Accreditation Council for Graduate Medical Education
(ACGME, 2003) (Philibert et al., 2002). The ACGME is the organization that sets standards for
postgraduate medical education and makes the rules for the work structure <strong>of</strong> interns and residencies
across the U.S. In 2003, the ACGME mandated a maximum 80 hour work week, restricted continuous
work shifts to 30 hours and insisted that house <strong>of</strong>ficers have one day <strong>of</strong>f per week. This reform
sought to create a minimum standard for duty hours across all training programs.
Not all involved with medical graduate education were in favor <strong>of</strong> the changes. The ‘downside’ <strong>of</strong>
resident work hour reform was a potential loss <strong>of</strong> continuity <strong>of</strong> care, reduction in trainee learning
due to reduced patient exposure and disruption <strong>of</strong> the educational units that provide care in a
teaching hospitals setting (Steinbrook, 2002; Charap, 2004).
The relationship among continuity <strong>of</strong> care, fatigued providers and patient safety is complex (Shojania
et al., 2001). Efforts to reduce fatigue and sleep deprivation among residents can result in increased
discontinuity <strong>of</strong> patient care, and just as with fatigued physicians, the result also can be harmful
(Cook, Render & Woods, 2000). Even since implementation <strong>of</strong> the work hour reform, those house
<strong>of</strong>ficers benefiting from the reduction in hours have noted potential negative impact on patient
care and their education (Goitein et al., 2005). Three years after initiating the reform, the effect <strong>of</strong>
this universal change in resident work hours on patient safety is not known. However, the sequence
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