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Correspondence |

14-Hour Shift Schedule for Medical ICU InternsFourteen-Hour Work Shift Model for Medical ICU House-Staff FREE TO VIEW

Akhil Vallabhaneni, MD; Dhruv Gadhia, MD; Paul Foster, MD; Mitchell Schwartz, MD; Michele Demusis, MD
Author and Funding Information

Affiliations: Greater Baltimore Medical Center Baltimore, MD,  Mayo Clinic College of Medicine Rochester, MN

Correspondence to: Akhil Vallabhaneni, MD, Greater Baltimore Medical Center, Internal Medicine, 6565 N Charles St, Suite 201, Towson, MD 21204; e-mail: avallabhaneni@gbmc.org



Chest. 2006;130(6):1947-1948. doi:10.1378/chest.130.6.1947
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We report here on an alternate version of the 14-h shift model for ICU residents that was described by Afessa and colleagues (December 2005).1 Shift schedules limit resident hours and shift duration; however, these undermine the intern’s traditional role of knowing the patient and passing on the complete clinical picture to the team each day. This makes it difficult for on-duty physicians to have an accurate and complete understanding of each patient. By deemphasizing morning rounds, shift schedules also challenge formal teaching by attending physicians.

We recently implemented a novel shift schedule that requires a day and a night intern be present for the duration of morning rounds. This allows all physicians who will be involved in a patient’s care for the next 24 h to participate in forming the care plan and eliminates the need for separate evening teaching rounds. Our interns rotate through a 7:00 am to 9:00 pm ICU admitting shift, a 7:00 am to 10:30 pm crosscover shift, and a day off; they then work the night shift from 10:00 pm to12:00 pm the following day for 4 days. We eliminated distinctions between weekend and nonweekend days to make it easier to schedule days off and to avoid staffing shortages on weekends. Our interns met the Accreditation Council for Graduate Medical Education requirements for rest periods and for weekly hours, averaging 72 h per week.

We found remarkable satisfaction among housestaff despite a 20% increase in ICU admissions. Interns reported “knowing the patients better,” being “better rested,” and having more efficient rounds. However, they found night shifts and frequent signouts to be difficult, and significant effort was needed to ensure adherence to rest periods. Although we did not assess patient outcomes, our interns’ comments suggest the presence of a better knowledge of patients and thus potentially improved patient safety. We suggest that further studies examine the potential benefit of work schedules that maximize attendance at daily rounds.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Figure Jump LinkFigure 1. Requirements of the Accreditation Council for Graduate Medical Education for rest periods and weekly work hours for interns.Grahic Jump Location

The authors have no conflicts of interest to disclose.

Afessa, B, Kennedy, C, Klarich, K, et al (2005) Introduction of a 14-hour work shift model for housestaff in the medical ICU.Chest128,3910-3915. [CrossRef] [PubMed]
 

Fourteen-Hour Work Shift Model for Medical ICU House-Staff

To the Editor:

We thank Vallabhaneni and colleagues for sharing their experience of a 14-h shift schedule of interns in a medical ICU. The shift model we described in our article (December 2005)1has the potential to adversely affect the continuity of patient care. The model described in the letter by Vallabhaneni and colleagues provides a partial solution to the discontinuity of care. Although the letter does not include any objective data, the interns’ reporting of satisfaction and feeling of familiarity with the patients’ conditions are promising. We may not be able to develop one model that will fit all teaching programs. The optimal resident staffing of an ICU depends on patient mix and availability of attending physicians and critical care fellows. Ideally, attending physicians should be available 24 h/d and 7 d/wk in the ICU.2 The availability of attending physicians provides an opportunity to provide both good patient care and house-staff education, with more than once-a-day teaching rounds when needed. However, lack of resources and shortage of intensivists may not allow all teaching programs to have qualified intensivists in the ICU 24 h/d to guide both teaching and patient care. The model described by Vallabhaneni and colleagues provides an alternative approach. Since their model requires each intern to be on night duty only once every fourth day, its impact on sleep hygiene may be better tolerated than the model described in our study. However, when we introduce a new house-staff/patient care model in an ICU, we need to measure its impact on patient outcome, clinician satisfaction, sleep hygiene, and education. Such an approach may help educators and clinicians to identify the best model.

References
Afessa, B, Kennedy, CC, Klarich, KW, et al Introduction of a 14-hour work shift model for housestaff in the medical ICU.Chest2005;128,3910-3915. [CrossRef] [PubMed]
 
Afessa, B Intensive care unit physician staffing: seven days a week, 24 hours a day.Crit Care Med2006;34,894-895. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Requirements of the Accreditation Council for Graduate Medical Education for rest periods and weekly work hours for interns.Grahic Jump Location

Tables

References

Afessa, B, Kennedy, C, Klarich, K, et al (2005) Introduction of a 14-hour work shift model for housestaff in the medical ICU.Chest128,3910-3915. [CrossRef] [PubMed]
 
Afessa, B, Kennedy, CC, Klarich, KW, et al Introduction of a 14-hour work shift model for housestaff in the medical ICU.Chest2005;128,3910-3915. [CrossRef] [PubMed]
 
Afessa, B Intensive care unit physician staffing: seven days a week, 24 hours a day.Crit Care Med2006;34,894-895. [CrossRef] [PubMed]
 
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