The Royal College of Surgeons of England

Transcription

1 The Royal College of Surgeons of England Do reduced doctors working hours create better safety for patients? assessing the evidence. From Commons opposition debate on EWTD March : Dr. Stoate: Is the Secretary of State aware of a report by Warwick and Harvard universities that showed that doctors who worked 56 hours made 30 per cent more mistakes than those working 48 hours? Even relatively few extra hours significantly increases the risk of making an error. Alan Johnson: Not only am I aware of that research, but I intend to quote it chapter and verse later. i The debate between government and the surgical profession surrounding the introduction of the 48 hour working limit has been technical and complicated. At the heart of the government argument for the shortening of working time is that doctors are tired and that being tired they make mistakes that harm patient care. But does the evidence exist to demonstrate that working over 48 hours per week is a direct cause of severe fatigue? The quote that opens this article from a recent commons debate seems to suggest so. But what is not acknowledged in the political debate is not just that the Warwick study is not just the only scientific paper anywhere that examines comparative safety of 48 hour working for doctors, but also that the way its results are used to support the case for 48 hour working is seriously flawed to the point of misleading. Does the Warwick study stand up to scrutiny? The problems begin even with the title itself: Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients safety: assessorblind pilot comparison ii.

2 The study does not investigate whether working hours greater than 48 hours per week is a risk it instead sets out to establish whether the reduction in hours itself causes harm. So it can provide no justification in favour of reduction just establish that reduction itself does not cause harm. But beyond this there are limitations that should cause concern about this being the touchstone study used to justify the case that 48 hour working: Small sample: the study follows just 19 junior doctors. Incomparable sample groups: the study compares groups with different risk and patient profiles with a group of nine doctors working 48 hour compliant rota on an endocrinology ward against a group of 10 working traditional oncall pattern on a respiratory ward. No difference in patient safety incidents: over the course of the study there were 60 patient safety incidents exactly 30 occurred in each study group. Sleep time unaltered: There were no statistically significant differences between the amounts of sleep in each group. Most damningly of all, of those 60 patient safety incidents reported during the study, only five in the non-ewtd group and four in the other were down to preventable errors by clinicians. To place in perspective, 47 of the incidents were caused by patient falls. Asking the wrong questions pattern of work v gross number of hours worked What is frequently ignored is that an hour spent working at 2am is qualitatively different from an hour spent working at 2pm. There simply has not been adequate research into the impact of full-shift working in the hospital environment and what papers do exist give a very mixed picture. But overall they suggest that gross number of working hours is a far too simplistic a measure to be used as a predictor for fatigue. When people work and how they work have at least as important an effect as gross total of hours worked, if surveys of trainees are to be believed iii. As long ago as 2005, a Royal College of Physicians survey of trainees on full-shift systems showed 81 per

3 cent reported excessive fatigue on night shifts and that 74 per cent had fallen asleep at work. Unintended consequences the impact of full-shift rotas The reduction to 48 hours alongside European rulings that time spent sleeping on-call in hospital is considered to be working have compelled Trusts to strip out layered oncall cover and replace with full-shift systems. Long-standing research in other industries has shown shift working is associated with interrupted sleep patterns, chronic tiredness and mistakes a recent statement by the Association of Surgeons in Training cited 15 separate pieces of research that found that shift working led to more errors than 24 hours on-call iv. The same survey showed that 71 per cent reported no improvement in work/life balance and 74 per cent felt shift systems had pressured their social lives. A recent study conducted for DH by University of Sheffield indicated that over half of Medical Directors said their Trust had not or that they were unaware of any risk analysis undertaken on the impact of 48 hour working in their area v. By way of contrast, other industry show just how carefully employers should take even minor changes to working hours. For example, when London Underground opted to make minor changes to their shift patterns at just two depots they undertook an independent University of Surrey study specifically to ensure there were no ill effects on drivers. They also ensured that it had the support from management, unions and health & safety experts vi. Other factors that affect morale and fatigue include acceptability of hours to the individual, how stressed and pressured they are and feeling of personal control over working life. Unfortunately these are precisely the conditions created when trainee surgeons are placed into strict rota shift systems that decrease their training opportunities at a key time in their career. An analysis in a US journal Medical Teacher by the University of Kentucky found that sleep adequacy itself was too simple a measure to judge quality of patient care and that it was when fatigue is combined with feelings pressure that mistakes happened. In their small study of 43

4 interns 38 per cent of interns who reported having made an omission in patient care did so when under high pressure and having had insufficient sleep vii. The surgical firm, where trainees are able to work through cases with their consultant, has been fractured by the introduction of new shift systems in many places. An assessment of Galway University Hospital in 2007 showed that SHO level trainees were being dissociated from their consultants and being organised into socalled surgical assessment units viii. The significance of formally stratifying surgeons in the hospital cannot be underestimated in terms of continuity of care and frustrating training. The same study found that level, quality and continuity of care for patients all suffered under EWTD restrictions. There is much evidence that excessive fatigue leads to impaired reasoning and motor skills. But it seems there is a real lack of evidence for how that condition in an individual can translate into harm for patients in the hospital environment. There is also a big gap in evidence for whether the 48 hour limit actually delivers on the goal of less fatigued doctors. This is important because policy built on scant observational data is causing significant unintended consequences. This is borne out by analysing the strategies used by UK hospitals to cope with the loss of almost 500,000 doctors working hours across the NHS ix. There is a much greater evidence base to suggest the full-shift system being brought in increase patient harm through greater handovers and stratification of hospital staff. The potential for important information to be missed and inability to access senior expertise at key times are a greater problem for patients. In the long term it is thought an additional 7,500 consultants might be needed to maintain NHS services under these new work patterns x. Whether this expansion is actually achievable given proposals to lengthen training xi and economic pressures is highly debatable. Even if it were, the effects on patient care of diluting the clinical workforce and thereby reducing specialist expertise have yet to be quantified. Matthew Worrall April 2009

5 i Hansard; March 10, 2009: Column 233. ii Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients safety: assessor-blind pilot comparison; F. P. Cappuccio et al; QJM. iii Cited in: Sleep, performance and the European Working Time Directive; N Douglas; Clinical Medicine; Vol 5 No 2 March/ April iv Optimising Working Hours to provide quality in training an patient safety; A position statement by the Association of Surgeons in Training; January v Survey on 48 hour week WTD readiness; NDS Bax et al; report prepared for Department of Health and shared with AoMRC. vi University of Surrey study for London Underground reported in university magazine Surrey Matters. vii Do pressure and fatigue influence resident job performance?; Christopher A Feddock et al; Medical Teacher; 2007; 29: viii EWTD Pilot assessment; JT Garvin et al; Surgeon; ;2: ix BMA estimate cited in: EWTD Pilot assessment; JT Garvin et al; Surgeon; ;2: x EWTD Pilot assessment; JT Garvin et al; Surgeon; ;2: xi Dr Wendy Reid, Eurpoean Working Time Directive Clinical Adviser - interview to Channel 4 News; March 2009.