Shifting to a New Model of Work

In March 2017, the Accreditation Council for Graduate Medical Education weighed in on a controversial debate throughout the medical community, deciding that first-year residents would be allowed to work 24-hour shifts — an increase from the historical 16 hours[1]. The medical and academic community was in turmoil. Experts on one side cited patient safety and decreased handoffs as a favorable outcome of the decision, while resident groups and academics stressed clinician fatigue and the potential for increased medical error as downfalls of the decision. Among all medical professionals, and particularly in anesthesiology, the debate on shift work remains — how long, when, and how difficult can a shift be before it leads to fatigue and, eventually, medical error? Research shows that different shifts trend towards different characteristics for type, number, and complexity of procedures. In a recent article from the Journal of Medical Systems, researchers aimed to perform a retrospective study to quantify the nature of daytime shifts versus after-hours shifts[2]. The study found that after-hour shifts patients had increased odds of having a non-operating room anesthesia environment, and were less likely to undergo complex procedures. This result was in contrast to the commonly-held perception that after-hour procedures are more dangerous — presumably, physicians are more sleep-deprived, and thus are more susceptible to making medical error. In fact, the centers sampled in the study from the National Anesthesia Clinical Outcomes Registry seemed to attempt to counteract the potential danger of after-hours shifts by scheduling fewer complex procedures.

In addition to changing the type of procedures completed on after-hours shifts, researchers have proposed several potential strategies to increase the safety and efficacy of procedures during after-hours shifts. The dangers of shift work are not restricted to anesthesiologists alone; rather, CRNAs also face the considerable barriers of on-shift fatigue. CRNAs are Certified Registered Nurse Anesthetists, or highly specialized Registered Nurses who undergo extensive training to become experts in anesthesia. CRNAs often experience comparable schedules to anesthesiologists, with approximately 43% of sampled CRNAs reporting fatigue occurring at least once each shift. A recent article in the American Association of Nurse Anesthetists reported on specific strategies that CRNAs use to minimize the strain of fatigue on work quality[3]. The journal reports that sampled CRNAs utilized short intermittent sleep episodes, exposure to bright light upon waking, and strategic caffeine use as effective tools to avoid fatigue.

On a larger scale, academics on the topic of shift work stress that while individuals can modify their behavior to include fatigue prevention techniques, it will take larger policy changes to create change at the hospital level. While the optimal model for shift work is yet to be decided, it is evident that the topic will remain a passionate discussion in the anesthesiology medical community for years to come.

[1] https://www.washingtonpost.com/news/to-your-health/wp/2017/03/10/first-year-doctors-will-be-allowed-to-work-24-hour-shifts-starting-in-july/?utm_term=.446df2673477

[2] https://www.ncbi.nlm.nih.gov/pubmed/28776233

[3] https://www.ncbi.nlm.nih.gov/pubmed/26016171

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