Awake and Informed
http://www.100md.com
《新英格兰医药杂志》
I grew up with the one-doctor–one-patient paradigm. When I admitted a patient, I took the case as my personal responsibility. I did my best to get to know the patient and his or her family, the medical problem at hand, and the best way to approach it. If this meant working without sleep, so be it — the patient came first. As my practice migrated more toward intensive care medicine, in which the approach to care is more team oriented, I retained a vestige of the old habits. Try as I might not to do so, I put more into the patients I admitted than the ones admitted by my colleagues. It is not that I did not pay attention to the care of patients admitted by others; I just felt more involved in the care of the patients admitted on my watch. Two articles by the Harvard Work Hours and Health Study Group1,2 in this issue of the Journal have convinced me that we need to replace the traditional system with one in which the responsibilities for patient care are shared by a team and that allows physicians to get more sleep.
Investigators at the Brigham and Women's Hospital in Boston studied the effects of modifying the on-call schedule of the interns on how sleepy they were and on the number of serious medical errors they made. When the traditional, every-third-night "long" shift (from morning rounds on day 1 through afternoon rounds on day 2) was divided between two interns, sleepiness and errors declined. The division was accomplished by bringing in a fourth team member, a new intern, at 9 p.m. on day 1. This split the long shift after sign-out rounds on day 1. The fresh intern would work overnight and stay with the team until the next afternoon. It should be noted that these studies were made possible only because the hospital administration was willing to open its intensive care units (ICUs) to scientific and public scrutiny.
During a small part of this study, I served as attending physician on the ICU during both the traditional (control) schedule and the intervention schedule. Although the interns were more awake and made fewer serious mistakes during the intervention schedule, they often knew very little about the patients who had been admitted the night before they came on duty. On these occasions, I had to base patient care decisions on information provided by the other resident who was working on the standard overnight-shift schedule or on personal knowledge gleaned from seeing the patient the day before. The intern coming on at 9 p.m. had helped care for the patient overnight but had not considered the patient as one of his or her cases.
The overall ICU performance in this trial was not exactly stellar, with 193 serious medical errors per 1000 patient-days during the traditional schedule and 158 serious medical errors during the intervention schedule. Overall, the rate of serious preventable adverse events was 38 per 1000 patient-days in both groups, meaning that 1 serious, preventable adverse event occurred every three to four weeks — a rate that is unacceptably high.
We all know from personal experience that we perform better with more sleep. In addition to having staff and call schedules that take into account the basic human need to sleep, we need to learn more about effective teamwork if we are to adapt to schedules that involve frequent handoffs. The key physicians on a team must learn the essential information about every patient, not just enough to get by. Such information needs to be stored in a standardized and accessible format. Our transfer of information must be complete, and we need to hone the skills involved in this transfer. We must be open with patients' families so that they understand that those caring for their loved ones will have had enough sleep to be at their best. We must be more than awake — we need to be awake and informed.
References
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.
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.
Related Letters:
Interns' Work Hours
Pennell N. A., Liu J. F., Mazzini M. J., Harnik I. G., Fessler H. E., Brotman D. J., Dwyer J. P., Cohen M. D., Evans A. T., Landrigan C. P., Lockley S. W., Czeisler C. A., the Harvard Work Hours, Health, and Safety Group(Jeffrey M. Drazen, M.D.)
Investigators at the Brigham and Women's Hospital in Boston studied the effects of modifying the on-call schedule of the interns on how sleepy they were and on the number of serious medical errors they made. When the traditional, every-third-night "long" shift (from morning rounds on day 1 through afternoon rounds on day 2) was divided between two interns, sleepiness and errors declined. The division was accomplished by bringing in a fourth team member, a new intern, at 9 p.m. on day 1. This split the long shift after sign-out rounds on day 1. The fresh intern would work overnight and stay with the team until the next afternoon. It should be noted that these studies were made possible only because the hospital administration was willing to open its intensive care units (ICUs) to scientific and public scrutiny.
During a small part of this study, I served as attending physician on the ICU during both the traditional (control) schedule and the intervention schedule. Although the interns were more awake and made fewer serious mistakes during the intervention schedule, they often knew very little about the patients who had been admitted the night before they came on duty. On these occasions, I had to base patient care decisions on information provided by the other resident who was working on the standard overnight-shift schedule or on personal knowledge gleaned from seeing the patient the day before. The intern coming on at 9 p.m. had helped care for the patient overnight but had not considered the patient as one of his or her cases.
The overall ICU performance in this trial was not exactly stellar, with 193 serious medical errors per 1000 patient-days during the traditional schedule and 158 serious medical errors during the intervention schedule. Overall, the rate of serious preventable adverse events was 38 per 1000 patient-days in both groups, meaning that 1 serious, preventable adverse event occurred every three to four weeks — a rate that is unacceptably high.
We all know from personal experience that we perform better with more sleep. In addition to having staff and call schedules that take into account the basic human need to sleep, we need to learn more about effective teamwork if we are to adapt to schedules that involve frequent handoffs. The key physicians on a team must learn the essential information about every patient, not just enough to get by. Such information needs to be stored in a standardized and accessible format. Our transfer of information must be complete, and we need to hone the skills involved in this transfer. We must be open with patients' families so that they understand that those caring for their loved ones will have had enough sleep to be at their best. We must be more than awake — we need to be awake and informed.
References
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.
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.
Related Letters:
Interns' Work Hours
Pennell N. A., Liu J. F., Mazzini M. J., Harnik I. G., Fessler H. E., Brotman D. J., Dwyer J. P., Cohen M. D., Evans A. T., Landrigan C. P., Lockley S. W., Czeisler C. A., the Harvard Work Hours, Health, and Safety Group(Jeffrey M. Drazen, M.D.)