May 20, 2008


Filed under: ACGME WAKE UP CALL — Tags: , , , , , , , — Kim Sanders-Fisher @ 1:01 am

Should ACGME demand a more proactive approach to fatigue management with safer levels of basic staffing in teaching Hospitals as a condition of accreditation?   

        It takes a complete Medical Team with fully alert practitioners to deliver safe patient care. But Deliberate Negligent Understaffing of clinical units, and a cursory adherence to providing adequate on-call arrangements to facilitate quality sleep, adversely impact the ability of American Doctors in training to cope with fatigue and avoid unnecessary Medical errors.   

         In a landmark case Whistleblower Troy Madison reported prestigious Johns Hopkins Hospital to the ACGME when he felt that his fatigue due to non-compliance with the work hours regulations had almost compromised the care of one of his patients.  Was this an isolated incident involving just one teaching facility or indicative of a far greater problem industry wide?  In a for profit healthcare system there’s a tremendous incentive to do more with less and our Doctors in training are being forced to compensate for the drastic consequences of understaffing.  If a well financed institution like Johns Hopkins Hospital was overworking their trainees how are smaller facilities coping with the financial pressure to make cuts.  The Troy Madison case certainly proved that even the most iconic Hospital in the country was prepared to push their trainees to the absolute limit of physical endurance in total denial of the reality that it might easily cause serious harm to patients.  Denial regarding the negative impact of fatigue is all too common in Medicine and we need to enforce regulatory safeguards to combat this danger.  

         Should we be pushing Doctors to the limit of exhaustion endurance?  It is far too simplistic to merely regulate how long someone in training is allowed to spend continuously on-call.  Hospitals are not proactively facilitating the opportunity for key Medical staff to obtain sufficient rest in dedicated sleeping areas while on-call.  Despite ACGME mandates, those in training frequently go without sleep for dangerously long periods of time, even while keeping strictly within the current regulations for maximum time on duty.  We are expecting these Doctors to absorb knowledge and safely treat vulnerable patients by functioning flawlessly in a state equivalent to being legally drunk!  At the end of an extensive period of stressful Medical duties no one is monitoring whether they are still fit to drive home without causing an accident! “Power Napping” in a comfortable sleeping arrangement like the EnergyPod pictured below is highly preferable to the current grossly inadequate alternatives that fail to acknowledge the importance of sleep with regard to the alertness of Medical staff. 

                         Authorized by & Created for MetroNaps to provide public information

The dirty little secret is that Residents are not expected to get quality sleep during lengthy stints on duty and are deliberately discouraged from leaving critical clinical areas like the ED.          
         While I agree that continuity of care is best delivered while maximizing learning opportunities in long hours of work to provide greater exposure to clinical practice, this becomes non-productive when Doctors in training are chronically fatigued.  Currently this excellent goal is all too easily manipulated to justify zero sleep.   This situation has been getting steadily worse exacerbated by the Deliberate Negligent Understaffing of clinical units to cut costs.  When assistive staff and uncommitted temps, with grossly insufficient numbers of regular Nurses, are there to back up the efforts of eager trainees, our future Doctors are increasingly exploited as a free labor source.   

           Does ACGME have the power to set required standards for teaching facilities as a condition of accreditation and what changes might they consider making?
1.        Stringent multidisciplinary minimum basic staffing requirements as proposed by the C.U.T!  Campaign Goals to CONTROL UNDERSTAFFING TODAY.
2.      Regulation of tasks to insure that Nursing and Ancillary staff take far greater responsibility for duties that are not essential for Doctors in training.
3.      Easily accessible dedicated quality sleeping arrangements to proactively facilitate adequate rest while on-call with monitoring of usage by those on-call to determine if they are obtaining safe minimum sleeping time during extended periods on duty.

               ACGME must deny accreditation to teaching facilities that do not meet standards!  

          You might well ask what qualifies someone who is not an MD to talk with any authority about fatigue?  I have come from a rather unusual background of extensive overseas travel and many years at sea.   My Medical training, such as it is, represents a second career after spending most of my adult life working aboard private sailing yachts.  While that might sound far too cushy to even justify the title of “job” let alone “career,” it was actually very challenging on occasion and surprisingly hard work.  You learn a lot about fatigue at sea, how to pace yourself, plus how to insure that all of your crew remain fit and well rested.   There are times when you are faced with a serious crisis, dealing with a life threatening emergency, but the second time allows, your solemn duty to your crew is to get quality sleep.  It is just as hard for Medical professionals to unwind following critical emergency procedures, but getting sufficient rest is a duty for them too.  

The importance of the duty to be well rested is not outweighed by the critical nature of your workload, rather it is necessitated by the skill and complex decision making involved in such tasks. The impact of sleep loss and fatigue in Residency training is well documented in Medical journals like this one in JAMA:  

         My last few years at sea I did many ocean passages sailing double handed. Dealing with fatigue when there were only two of us to take watches, steer the boat, navigate and cope with extreme conditions offshore took stamina, self-reliance and good planning.  As a yacht delivery Captain I learned to deal with serious emergencies at sea, not panic, but instead use innovative strategies to think through problems logically.  Keeping a clear head by paying attention to my own basic need for regular sleep was an essential duty of command.  It is time US Medical facilities stopped treating their Medical professionals as if they were super-human and sleep was a superfluous luxury: without rest mistakes are inevitable.  After surviving dismasting, injury, a full capsize and watching my best friend washed overboard into the freezing Southern Ocean on the Whitbread Round the World Race, I strongly maintain that most disasters at sea are the result of “Panic, Fatigue or Complacency.”  I once gave a lecture on this sponsored by West Marine; but, how many errors in our Medical facilities are caused by these exact same issues?   

How often are our Medical professionals compromising their ability to cope, diminishing the standard of their care or narrowly avoiding unnecessary errors by suspending the reality of their need for sleep?   Do they even drive home safely?          

         Following my experience on the Whitbread race I became convinced that “fatigue” was a major factor in precipitating mistakes; it was the hidden element all too often overlooked by hardened professional crew.  Ignored impediments like the cold, wet gear, damp sleeping bags, lousy nutrition, stringent water rationing and plain old lack of sleep, rendered even the world’s top sailors more prone to dangerous errors and impaired their efficiency with less than impressive racing results. I created “Team Pro-Maxi,” my own team of internationally renown women sailors, determined to pay attention to the debilitating details of fatigue in our bid to win the 93/94 Whitbread race.          

         Fate intervened when Hurricane Andrew devastated south Florida; my personal ambitions were transformed by this first experience working as a Medical Volunteer in the aftermath of a major disaster.  I made an abrupt career change seeking additional Medical training with the lofty goal of working in disaster relief.  However, when I entered a conventional Hospital setting I had great difficulty trying to adapt and learn to stifle or ignore the tell tale warning signs of fatigue among my overwhelmed coworkers in the Medical staff.  I would observe with pity as an exhausted Resident tried to doze off bolt upright in a chair behind the Nursing station, right opposite one of our “Baker Act” restrained patients whose tormented screams further intensified the general mayhem of the Surgical ER at 2:00AM on a Saturday night. The Residents call room was too far away from the ER for practical purposes so this harrowing scenario was what constituted “rest” during 36 hours of continuous duty!  How many regular human beings could cope with that? It is accepted practice, Medical professionals rarely complain, but what impact does this have on the safety of patient care?  We are naive to pretend that it doesn’t matter.   

Why do so many Hospitals knowingly create torturous conditions for their Medical staff who desperately require quality sleep? Do they really still expect them to remain alert and focused on critical live saving interventions?  

           I am not one of those who believe that it just takes intelligence and good grades to become a Doctor, it takes phenomenal stamina as well. Today’s Medical students and Residents must face the cynical comments of older Doctors who will insist that they coped so well with almost zero sleep and mounting patient care responsibilities.  However, it does not have to be this way, and besides, the exaggerated claims of having coped with an equally demanding schedule are not quite true.  There is at least one added dynamic that I am sure most Doctors in training are already aware of: the greatly increased acuity of the current typical Hospital patient.  If the patient is not half dead they are discharged; not such a bad idea considering the rise in nosocomial (Hospital acquired) infection rates.  However this leaves Medical staff to care for only the very sickest individuals with the same demanding Residency routine under which their predecessors worked so well.      

        But wait there’s more, yet another important dynamic affecting the workload of Medical Students and Residents that they might be far less aware of: the Deliberate Negligent Understaffing of clinical units.  This does not yet fall under the jurisdiction of ACGME Medical program rules or even include Doctors in training, but it does impact the overall workload and the current debilitating lack of time to rest up while on duty.  This growing problem has been getting steadily worse since the 90s and has reached epidemic proportions as money hungry Healthcare Corporations have now managed to precipitate a nationwide “Nursing Exodus” in America.   

Q:      How do Nursing and ancillary staff numbers affect Medical Students and Residents?  
A:      Simple, when fewer people are available to tackle routine tasks, those in training end up picking up the slack, often doing simple jobs that require little or no Medical experience at all.           

          When those confident Doctor mentors faced the rigors of Medical Residency there were more Nursing staff, plus the training, experience and skills of those on duty was more comprehensive while they were also far less fatigued by unreasonable work demands.  Bottom line: they had great backup!  When basic Nursing and unskilled drudgery jobs are not done they seriously disrupt the work flow, so people who should really prioritize their own need for rest during long hours on duty, do not hesitate to pitch in.            

         An ER patient has been waiting for ages just to go to X-Ray, no one is available for transport, so the compliant Resident does the brief transport detail so that another of their patients can progress though treatment. I know this sound petty, a minor detail, but all too familiar to many who have endured Residency in a busy county Hospital.  I am not suggesting that certain people are above such basic tasks, but if the real goal is training and gaining sufficient rest to function safely without causing harm to patients, we simply must prioritize with regard to who does what. It is the cumulative affect of dozens of mindless unskilled tasks like this that seriously eat into the rest-time when Medical Students and Residents should be recuperating to stay alert. These routine jobs are usually done by minimum wage assistive personnel, but when those in training shoulder the burden the Hospital can hire fewer people and that fattens their bottom line.  

Regulating this overlooked dynamic, with mandatory basic staffing requirements as a prerequisite of ACGME accreditation, would insure that the entire duty period was either spent productively, doing complex tasks that reinforced the skills and experience of Medical training, or recuperating in readiness to function safely.  

         I have witnessed three separate consultancy firms at two different Hospitals analyze the ER and OR in order to find ways to “trim the fat.” On all three occasions the answer was exactly the same: “you are top heavy, trim down on your Management positions.”  Managers control this ridiculous situation and they aren’t about to authorize their own redundancy! By ignoring the advice of Consultancy groups and eliminating jobs at the very bottom they will make the least possible difference to payroll, but time after time this is the strategy of choice.  There is a hiring freeze and positions are not filled as people leave.  The overworked staff must learn to do more with less; every day becomes another overwhelming emergency, but at teaching Hospitals part of the burden caused by understaffing is alleviated by dumping on Doctors in training.  This is all at great detriment to the safety of patient care.     

         Encouraging experienced higher paid staff to leave only to replace them with barely trained new Nurse grads and entry level assistive personnel also saves money for greedy Managers serving Corporate interests.  Medical Students and Residents unwittingly assist them in implementing this dangerous strategy by filling in for missing Nursing and ancillary staff while compromising their precious sleep. There are fewer Nurses available to monitor far sicker patients and less people to implement thorough cleaning just as Hospital bugs are becoming more virulent and resistant to antibiotics.  There is no redundancy of personnel, a glut of unfamiliar Agency staff, minimal breaks, frequent mandated overtime and excessive call among the people who are there to support a young Doctor’s work.  This is a recipe for disaster! 

         When all of the regular staff are overwhelmed and exhausted, there is a far greater potential for oversights and mistakes that more senior Medical colleagues might well be held partially or totally responsible for not preventing.   This is the completely unnecessary part of learning from your mistakes: Doctors do not need to blunder through training in a sleepy, guilt ridden haze!

         The good news is that this is not an irreversible mess.  Nurses who have left Hospital care in disgust still maintain their licenses and could be lured back. Tenured Nurses are higher paid, more experienced professionals who are therefore far less desirable to cost-cutting Management.  But, highly trained key personnel were the first to be targeted and encouraged to leave. The most senior Nurses were forced out by intolerable work demands and unsafe patient care compromises.  Their departure made room for inexperienced new Nurse Grads who should not be overstressed with inappropriate responsibility while still attempting to learn.  These new Nurses are more compliant with excessive work demands and far less likely to speak up about dangerous negligent practices.  This helps the Hospital to cut a few more corners and still make a big fat profit.

         Unfortunately these new Nurse Grads are ill equipped to teach the ancillary staff and supervise proper cleaning as they are barely able to cope with their own duties.  While they might not yet possess reliable qualities with regard to backing up the Medical team, they could easily learn if more experienced Nurses returned to the workforce to train them properly.  Unless the current unhealthy situation changes more Nurses will join the exodus as Nurse burnout is swift under such intolerable extremes.  If we do nothing, then even rawer recruits will soon take the place of the last remaining tenured staff to make the clinical areas even more marginal and unsafe for patient care.  This is disastrous for patients: unsafe care, higher infection rates, a greater potential for avoidable Medical errors and longer periods of abandonment with fewer qualified staff on duty.  

This also means receiving Medical treatment from an exhausted Doctor who is running on empty; another accident waiting to happen.             

         While exploiting Doctors in training continues to facilitate Deliberate Negligent Understaffing this dangerous trend will continue. How much do Residents benefit by becoming familiar with pushing stretchers and what can they possibly hope to learn when they are barely able to remain awake?  We are sabotaging vital elements of their training experience, while leaving them vulnerable to making serious mistakes that will torment their consciences just as they start into their new career.  Doctors do not operate in a vacuum, they need reliable backup with diligent patient monitoring, but they must also be relieved of the unskilled tasks that eliminate their only opportunity to rest while on duty.          

         Teaching Hospitals must do more than just provide the barest minimum token number of bunks in a remote on-call room relegated to an obscure section of the Hospital too far from high stress clinical areas for any practical use.  Call rooms do not have to accommodate cumbersome conventional beds and could be far better equipped with ultra comfortable recliners making more efficient use of the space.  A Company called MetroNaps  have developed a specially designed sleeping pod for “power napping” called an “EnergyPod” that would be ideally suited for use during long periods on-call.  Additional equipment could be installed to facilitate note dictation while relaxing prior to taking a nap.  Doctors could carry a pass key to enter these quiet rooms for periods of rest that could be easily monitored and recorded to ensure that they got sufficient nap time during lengthy stints on duty.   

We monitor the rest periods of long-haul Truck Drivers, to ensure that they drive safely, and Airline Pilots, insisting that they must be fit to fly, but we ignore the sleep requirements of Medical personnel at our peril as it is costing lives.           

         Other employees among the Hospital staff might also request access to the call room or be ordered by a supervisor to take a nap if they demonstrated the need for rest.  Current Medical facility policy penalizes those who attempt to sleep while at work even when they are on a scheduled unpaid break period.  We can mandate overtime and force Nurses to take a double 16hour shift, but there is no responsibility to insure that they are sufficiently rested or fit for duty, despite obvious signs of fatigue!  Following an exhausting 12-16hours on task a tired employee might need to take a brief opportunity for a nap before driving home since serious accidents have occurred due to Medical staff getting behind the wheel of a car when they were not fit to drive. However, while Medical facilities are not considered negligent for ignoring this known risk, eliminating the dangerous potential of falling asleep at the wheel is not a well established priority. Proactive efforts to combat fatigue among all Medical staff do not end with facilitating the delivery of safe patient care while on duty; we must include responsibility for ensuring that they are able to drive home safely without causing an accident.   

“Never Create a Second Victim”  is a core principal instilled in all EMS and Rescue workers. This priority to avoid placing ourselves in any unnecessary danger also requires us to pay vigilant attention to our own ability to function safely by maintaining personal fitness for duty with regard to rest, hydration, nutrition, etc.  The continuing exploitation of Medical staff represents a completely avoidable, unconscionable level of negligence that risks creating multiple victims!        

         All Medical facilities would benefit from a proactive policy that recognizes and deals with staff fatigue, but this is especially relevant for Doctors in training who are also attempting to learn at the same time.  This will reduce the likelihood of unnecessary Medical errors and ensure that key employees are ready to face a genuine emergency refreshed and alert: this is a frequently overlooked vital component of emergency preparedness with regard to Medical staff. The suggested radical change of attitude regarding rest requirements is precisely the type of proactive strategy towards fatigue that constitutes routine practice for all safety conscious Captains at sea, but it is long overdue for implementation within the healthcare industry.  On passage we cannot risk having any crew member fall asleep while on watch during a time period where we are completely reliant on their vigilance: a serious accident or collision might occur.   

At sea no one has ever needed to wake me up for my watch: I wakeup automatically.  Ashore I never use an alarm clock. I rely on these indicators to reassure myself that I am getting sufficient sleep to function safely and effectively.         

         Why are Medical staff not treated in a similar manner with due respect for their need to remain alert and focused on the safe care of their patients?  Why do Medical facilities prefer to torture their Doctors in training with endurance marathons in critical clinical areas when a nap as brief as 20 minutes within a sleeping pod like the one below would help them to recharge and recoup mid shift?

                         Authorized by & Created for MetroNaps to provide public information

ACGME should insist on more call rooms closer to clinical areas in addition to a proactive policy to remove the unnecessary workload created by Deliberate Negligent Understaffing. 

         Johns Hopkins Hospital was shocked to be called to account for breaking the work hour rules monitored by ACGME, after Troy Madison exposed the truth, but do these rules go far enough to ensure that Doctors in training get proper rest?  ACGME can no longer trust teaching Hospitals to provide sufficient staff to safely complement or complete their obligations with regard to the Medical team as a whole.  

         The current situation is in urgent need of change,So what can ACGME do to help turn this dangerous situation around? It is time for mandatory staffing minimums for Nurses, ancillary staff and even cleaners as proposed in the list of C.U.T! Campaign Goals.  Without meeting these minimum staffing requirements and instituting vital mandatory safeguards no facility should be able to obtain ACGME accreditation as a teaching Hospital.  

         These sanctions might sound harsh, but teaching Hospitals must take proper responsibility for genuinely facilitating the learning process and this is not accomplished on zero sleep.  Teaching facilities that fail to employ sufficient Nursing and support staff, exploit those attempting to learn, and neglect to provide necessary sleeping arrangements, do not deserve the privilege of training the next generation of American Doctors.   

A prestigious reputation for Medical excellence does not negate the obvious danger of ignoring important issues like fatigue! 

         The situation here in the UK, where I now live, might be even worse as reported in this piece that describes a widespread trend towards the elimination of on-call room in NHS Hospitals:   Please leave your comments. 




At both of the Hospitals where I worked, first in the ER (A&E) then in Surgery, the survival instincts that had saved my life so many times at sea were immaterial to unimaginative Managers focused on cost-containment. They felt threatened by any suggestions or creative input: I was removed from my OR job by an untimely and unjustified dismissal.  So now, I Blog! 


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