 A
nurse wakes you up from the only hour you've slept in
the last 30. It's four in the morning and time to do the
rounds in the ICU. There are over a dozen patients to
check on — no easy task given that many of their
charts are incomplete or missing. You schedule diagnostic
tests and administer medication to the most critical patients,
not realizing that you're duplicating some things already
done earlier in the day. Then the ER pages you. Looks
like these patients will have to wait for another hour.
These are the kinds of working
conditions facing physicians — usually residents
— working the dreaded graveyard shift in hospitals
across Canada. Out-of-hours on call has always been
the resident's cross to bear. But what would happen
if Canada followed its industrialized peers and drastically
limited residents' working hours? Who would fill the
nighttime gap?
A new project from across the pond
may provide a clue — and a beacon for the sleep-starved
working the red-eye rotation. In May 2003, the UK's
health service began a pilot program called 'Hospital
at Night,' which aims to tackle the inherent difficulties
of complying with the European Union's August deadline
for reducing residents' workweek to a mere 58 hours
through a major overhaul of hospital human resources
management.
Last month, the British Medical
Association released a progress report on the project.
The results indicate that out-of-hours staffing levels
do not reflect the fact that hospital activity drops
considerably between midnight and 8am at each of the
project's 11 test sites. They also found that much of
the nighttime caseload was non-urgent and could be handled
in the morning, and that residents were spending much
of their time on tasks that had already been performed
by another doctor, or that could have been performed
by a nurse or other healthcare professional. The main
solution being recommended is that instead of staffing
hospitals with one resident from each specialty, hospitals
should operate at night with a smaller, multidisciplinary
team made up of a mix of attendings, residents, nurses
and other staff who can provide all necessary care.
According to the project's organizers, this all amounts
to less in-house calls, meaning physicians are better
rested, resources are used more efficiently, and ultimately,
patients are better cared for.
But could this drastic change to
residents' hours and nighttime hospital staff work this
side of the Atlantic? And would our residents welcome
the change?
RESIDENT
NIGHT OWL
"If somebody had said to me at the beginning of my five-year
residency 'you can do it in seven years, but you'll
never have work at night,' to be honest, I would not
have chosen that seven-year route," says Dr Neety Panu,
a second-year radiology resident at the Royal University
Hospital in Saskatoon.
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Not a creature was stirring
Key recommendations
of the 'Hospital at Night' interim report:
- Use local data to re-assess
thinking about which staff need to be resident
in hospital out of hours
- Improve the way evening
work is managed and resourced to reduce nighttime
workload
- Improve the way information
is passed between staff to reduce
- the number of clinical incidents
at night
- Supervised multi-specialty
handover in the evenings
- Other staff taking on some
of the work traditionally done by residents
- Move a significant proportion
of non-urgent work from the night to the evening
or daytime
- Reduce the unnecessary duplication
of work by better coordination
For more information on the
project and to read the full report, please visit
www.modern.nhs.uk/hospitalatnight
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Dr Panu is a board member of the
Professional Association of Interns and Residents of
Saskatchewan (PAIRS), one of eight organizations responsible
for negotiating working conditions in the contracts
between residents and their respective province. She's
also an extreme athlete who has run marathons over 24
hours — perhaps not surprisingly one of her favourite
shifts is the 36-hour in diagnostic imaging. She insists
that, like her, most of her colleagues are content with
current working hour regulations — one night in
four in-house on call, followed by 24 hours off-duty.
Likewise, most see gruelling night shifts as a crucial
part of their training in becoming independently-thinking
physicians.
This kind of attitude doesn't surprise
Dr Jeffrey Lipsitz, who's treated many young physicians
at his Sleep Disorders Centre in Toronto, the largest
of it's kind in Canada. But he says the situation isn't
sustainable and insists we need to put greater emphasis
on maintaining a well-rested workforce if we hope to
avoid widespread burnout. He points out that the SARS
crisis showed us just how vulnerable our overtaxed medical
workforce can be. "We ought to recognize there's a problem.
One possible solution to be considered is to allocate
hospital staff, much in the same way as nurses are,
like a routine, industrial shift-work operation," he
says. "House staff have little if any opportunity to
adapt to night shifts and basically have to carry on
with their duties, regardless, which puts everyone at
considerable risk," he says.
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