点击显示 收起
医学研究中心(Institute of Medicine，IOM)的一篇新报告建议，藉由减少住院医师的值班时数与增加他们的睡眠时间，来减少住院医师疲劳相关的失误与改善病患安全及医学训练，增加工作时的监督。本报告标题为“住院医师值班时数：促进睡眠、监督与安全”，是由美国健康与人类服务部的健康照护研究与品质中心(AHRQ)所赞助，线上发表于12月2日。
AHRQ主任、Carolyn M. Clancy医师在新闻稿中表示，IOM研究提供了清楚的证据，支持我们一直以来所深信的—疲劳增加人类犯错的机会。最重要的，此报告提供了可改善病患安全、与增加住院医师训练品质的实际建议。
一IOM委员会进行了15个月的研究，检视住院医师工作时间表、工作表现、提供之照护品质之间的关系。根据研究发现，有急性和慢性疲劳的住院医师比较会犯错。
美国医学院协会健康照护主任Joanne Conroy医师在被邀请对IOM的报告进行独立回顾时向Medscape Medical News表示，住院医师因为长工时引起之疲劳的影响是关注所在。我们相信改善住院医师的工作，将能够获得较安全的临床环境，但这项资料还没有统计上的意义。
Conroy医师指出，10多年前发表的研究首度指出疲劳对表现的影响。
Conroy医师表示，当Dawson和Reid首度发表疲劳对表现的影响、且用酒精性失能比对时，医学界开始注意。之后，我们也承认医师认知与处理自己疲劳程度的因应有相当大的变化。
美国医师毕业后医学教育评鉴委员会(ACGME)目前的规定许可住院医师最长30小时的值班，包括直接照护病患24小时以及6小时的训练或过渡活动，这些规则也许可每周最多80小时的工时。
根据他们的研究结果，IOM委员会建议对这些规则进行许多改变。特殊建议如下：
* 完成30小时值班的住院医师，最多只可照顾病患16小时，之后在晚上10点到早上8点间有5小时的保护睡眠时间，这段期间的病患照护交由其他没轮到睡眠的住院医师或者其他的工作同仁。
* 应增加工作时的监督，因为经常发生未被报告之违反ACGME的情况。IOM委员会建议，定期的独立回顾住院医师工时，以及增加对那些指出没有遵照工时限制者的保护。
* 有关兼差的限制应该增加，内部和外部兼差都应纳入ACGME的每周80小时限制内。内部兼差定义为同一照护机构内的额外照护工作，目前被视为每周80小时的限制范围内。因为外部兼差会影响住院训练的休息与睡眠，可能会影响住院医师完成其主要职务的能力，IOM建议将内部兼差和外部兼差都纳入每周的工时限制内。
* 为了帮助从长工时中恢复，IOM 报告建议每个月保障5天休假，每周有24小时休假，每个月有一次48小时的休假。
* 住院医师院内待命时间应限制在每三个晚上一次。
* 因为住院医师在下班时的交通事故是上班时的两倍以上，医院应该提供安全的交通运输给那些疲劳而无法自己开车的住院医师。
* 住院医师交接班方面，应该使用结构式团队方法接受更多有关良好沟通的训练。这些交接随着值班期间缩短将会增加，可能会增加不良事件的风险，除非训练和团队沟通有所改善。
* 住院医师应多参与病患安全活动与不良事件报告，不只是为了改善照护品质，也为了促进他们的教育。
Conroy医师表示，病患安全是教育工作者、管理者和临床医师的第一优先。挑战将是如何发展一套策略来确保这些改变不会影响病患照护的连续性与教育的品质。
当被问到推广IOM所报告的建议是否会有障碍时，Conroy医师引用“试着建立一个适当的工作环境也可以产生最佳训练的医师”。
如果这些建议被广泛地实现，Conroy医师指出，目前的资料还不足以确认对健康照护的效果。
Conroy 医师结论表示，总是有非故意的结果。不过，我们预期那会有额外的成本。
在12月3日，新英格兰医学期刊线上发表一篇对于IOM的建议观点，指出病患安全、住院医师安全与住院医师教育这三个主要目标之间有时候有一些冲突。
纽约市的实习医师与住院医师委员会(Committee of Interns and Residents，CIR)提倡住院医师工时改革，促成有关此议题的辩论。
CIR总裁、纽约市皇后区的一名老年医学专家L. Toni Lewis,医师在新闻稿中表示，这篇新报告的建议佐证了我们提倡多年的、有关长工时对病患照护与住院医师良好训练是有危险性的论述。不过，我们希望IOM可以进一步支持16小时的限制。
医学研究中心。线上发表于2008年12月2日。N Engl J Med. 2008;359:2633–2635.
Institute of Medicine Recommends More Sleep, Fewer Work Hours for Residents
By Laurie Barclay, MD
Medscape Medical News
A new report by the Institute of Medicine (IOM) recommends strategies to reduce medical resident fatigue-related errors and improve patient safety and medical training by reducing residents' duty hours, increasing their sleep hours, and increasing supervision of work hour limits. The report, titled "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," was funded by the US Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) and was published online December 2.
"The study provides the clear evidence to prove what we have long-believed is true — fatigue increases the chance for human error," AHRQ Director Carolyn M. Clancy, MD, said in a news release. "Most importantly, this report provides solid recommendations that can improve patient safety, as well as increase the quality of the resident training experience."
An IOM committee performed a 15-month study examining the associations between residents' work schedules, their performance, and quality of care provided. Residents suffering acute and chronic fatigue are more likely to make errors, according to the study findings.
"The impact of resident fatigue caused by long work hours is still a major concern," Joanne Conroy, MD, chief health care officer, Association of American Medical Colleges, told Medscape Medical News when asked for independent review of the IOM report. "We believe that improved management of the resident work day may lead to a safer clinical environment, although the data has not yet demonstrated this statistically."
Dr. Conroy noted that studies published more than a decade ago first demonstrated the effect of fatigue on performance levels.
"When Dawson and Reid first published the effect of fatigue on performance and equated it with alcohol impairment, the medical community took notice," Dr. Conroy said. "Anecdotally, we also recognize the tremendous variation among physicians in terms of their ability to recognize and manage their own fatigue."
Current rules of the Accreditation Council for Graduate Medical Education (ACGME) permit a maximum 30-hour shift for residents, including direct patient care for 24 hours and training or transition activities for the remaining 6 hours. These rules also permit a maximum 80-hour work week.
On the basis of their study results, the IOM committee recommends several changes to these rules. Specific recommendations are as follows:
Residents who complete a 30-hour shift may treat patients for only up to 16 hours, followed by a 5-hour protected sleep period between 10 PM and 8 AM, during which time patient care would be managed by other nonsleeping residents or additional staff members.
Supervision of work hours should be increased because of frequent, often underreported lack of compliance with ACGME limits. The IOM committee recommends periodic independent reviews of hours worked by residents, as well as increased protections for those who report failure to comply with current work hour restrictions.
Moonlighting restrictions should be increased so that both internal and external moonlighting count against the ACGME 80-hour weekly limit. Only internal moonlighting, defined as additional paid healthcare work at the same healthcare facility, is currently considered to be part of the 80-hour weekly limit. Because moonlighting outside residency training affects strategically designed periods for rest and sleep and may hinder residents' abilities to complete their primary duties, the IOM recommends that both internal and external moonlighting be counted toward the total work week hourly limit.
To facilitate recovery after working long shifts, the IOM report recommends guaranteed 5 days off per month, with 24 hours off each week and one 48-hour period off each month.
Hospital on-call periods for residents should be limited to no more than every third night.
Because the risk for motor vehicle accidents more than doubles when residents drive home after working extended shifts, hospitals should provide safe transportation to residents who are too fatigued to drive home.
Residents should receive more training on better communication, using a structured team approach, during change-of-shift handovers. These handovers will increase as resident shift duration decreases, possibly increasing the risk for adverse events unless training and team communication improve.
Residents should be more involved in patient safety activities and in adverse event reporting not only to improve quality of care but also to enhance their educational experience.
"Patient safety is a top priority for educators, administrators, and clinicians," Dr. Conroy said. "The challenge will be how to develop a strategy to ensure that these changes don't impact the continuity of patient care and the quality of the educational experience."
When asked whether there are barriers to widespread implementation of recommendations in the IOM report, Dr. Conroy cited "trying to create an optimal work environment that also produces the best-trained physician."
If these recommendations are widely implemented, Dr. Conroy pointed out that data are currently insufficient to determine the effect on healthcare.
"There will always be unintended consequences," Dr. Conroy concluded. "We would expect, however, that there will be additional costs."
On December 3, the New England Journal of Medicine published online a perspective on the IOM's recommendations, noting tensions among 3 main objectives that are sometimes in conflict: patient safety, resident safety, and resident education.
The Committee of Interns and Residents (CIR) in New York City, an advocate for resident work hours reform, contributed to the debate on this issue.
"The recommendations in this new report are an important corroboration of our advocacy over the course of many years about the dangers of long hours to patient care and to resident well-being," CIR President L. Toni Lewis, MD, a geriatrician in Queens, New York, said in a news release. "We had hoped, however, that the would go farther in its support for the 16-hour limit."
Institute of Medicine. Published online December 2, 2008. N Engl J Med. 2008;359:2633–2635.