HEALTH AND SAFETY

» Drug, Devices, and Supplements

» Physician Accountability

» Consumer Product Safety

» Worker Safety

» Health Care Delivery

» Auto and Truck Safety

» Global Access to Medicines

» Infant Formula Marketing

 

More Information on Medical Resident Work Hours

Petition to Reduce Medical Resident Work Hours

September 2, 2010

PART  3: EXISTING HOURS LIMITATIONS FOR RESIDENT PHYSICIANS AND NON-RESIDENT PHYSICIANS

A. Current Work Standards

The U.S. has responded to the problem of excessive resident physician work hours in ways that have so far proven inadequate. It was only in 1981 that the governing body with authority over all U.S. residencies, the Accreditation Council for Graduate Medical Education (ACGME), began to require that resident physicians have any time to rest at all.[1] In 1984, an 18-year-old woman named Libby Zion died in a teaching hospital in New York City. Her father alleged the death was due to poor care given by tired, overworked, and badly supervised resident physicians. In response, a grand jury recommended residency improvements, and in 1987, the Bell Commission (named after Bertrand Bell, M.D., who is also a signatory to this petition) was formed, suggesting specific limits on resident physician work hours. Finally, in 1989, the New York legislature passed section 405 of the New York State Health Code, which charged the New York State Health Department with enforcing an 80-hour maximum work week. ACGME then followed with work-hour restrictions on some specialties, but it wasn’t until 2003 that ACGME issued universal rules. These changes included:

  • An 80-hour work week averaged over four weeks, including in-house call;
  • A maximum onsite work shift of 24 hours with up to six additional hours of educational or patient transfer-related activities, which has been universally interpreted as a 30-hour shift;
  • Call no more frequently than one night in every three, averaged over four weeks;
  • One day in seven off without educational or clinical duties, averaged over four weeks.

The ACGME promised to revisit the 2003 rules in five years.[2] In 2008, the Institute of Medicine issued a report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”. The IOM report was the product of an exhaustive 12-month review by a panel of experts charged with examining the existing system of medical training and the evidence regarding fatigue, resident physicians, and patient safety. The Institute concluded that it is unsafe for resident physicians to work for more than 16 hours without sleep:

The Committee believes there is enough evidence from studies of resident physicians and additional scientific literature on human performance and the need for sleep to recommend changes to resident training and duty hours aimed at promoting safer working conditions for residents and patients by reducing resident fatigue. [3]

The Committee made far-reaching recommendations for change in the training of resident physicians. Key recommendations are summarized below:

  • No change to the 80-hour work week, averaged over four weeks;
  • A maximum shift length of 16 hours. If a training program wanted to continue with a 30 hour shift, it must provide a mandatory five-hour protected sleep period between 10 p.m. and 8 a.m., with no new patients admitted after 16 hours;
  • Maximum in-hospital call frequency every three nights (not averaged over four weeks)
  • At least one 24-hour period off per week (no averaging) and at least of one 48-hour period off per month;
  • Night work must not exceed four consecutive nights and must be followed by a minimum of 48 continuous hours off, if three or four shifts are worked;
  • There must be 10 hours off after a regular work shift, 12 hours off after night work, and 14 hours off after an extended duration (> 24-hour) work shift (and the physician must not return before 6 a.m. the next day).

On July 8, 2010, the ACGME issued new recommendations of its own, the majority of which do not heed the Institute of Medicine’s recommendations:

  • No change to the 80-hour work week, averaged four weeks;
  • Maximum duration of work shifts for interns (first-year resident physicians) that do not exceed 16 hours;
  • Intermediate- and senior-level resident physicians (second year resident physicians and higher) can still be scheduled for 28-hour shifts (24-hour shifts with an additional four hour period to provide for education and patient transfer responsibilities);
  • Maximum in-hospital call frequency of every third night, no averaging;
  • One day off per week, averaged over four weeks;
  • Weekly work-hour exceptions of up to 88 hours per week;
  • Resident physicians must not be scheduled more than six consecutive nights of night work;
  • Resident physicians must have eight hours off between work shifts, with some exceptions.

In sum, the ACGME proposed new rules fall far short of the improvements recommended by the IOM and those necessary to protect patients and resident physicians from harm. The 80-hour workweek requirement should not be averaged over 4 weeks, as ACGME suggests. This would continue to allow programs to regularly work resident physicians more than 80 hours in a given week but still average 80 hours per week over four weeks. The proposed standards would permit interns to work up to 20 consecutive 16-hour shifts, which could occur, for example, during a three-week ICU rotation. Harm to resident physicians and errors that adversely affect patient safety result from fatigue, and working 90 or 100 hours in a single week provides inadequate time for recovery sleep. Such a work schedule could lead to a level of impairment associated with sleep deprivation that would far exceed that induced by working 30 consecutive hours. This could thereby result in a greater degradation of resident physician safety and patient safety than what results from current practice.

The recommendation that intern (first-year resident physician) shifts be capped at 16 hours is a positive development, but it should apply to all resident physicians. There is no biological rationale to support the notion that interns suddenly become able to withstand the proven deleterious effects of extended shifts upon completing their internships. That most of the studies showing the risks of fatigue were conducted amongst interns[4] does not mean upper-level resident physicians do not suffer fatigue from sleep deprivation too. Extensive data from the laboratory and a growing body of literature from clinical settings indicates that resident physicians’ performance deteriorates in the same manner as interns working extended shifts. Resident physicians are at increased risk of motor vehicle crashes after working for 24 hours.[5] Their risks of making medical errors are elevated both when conducting simulated procedures,[6] [7] [8] and more importantly, when providing care in clinical settings. [9] Even with interns’ work hours held constant, elimination of upper-level resident physicians’ 24-hour shifts is associated with a decrease in medical errors and patient mortality.[10] [11] After studying this issue for more than a year, the IOM of the National Academies — a multi-disciplinary body of experts from across fields — concluded that it was unsafe for any resident physician to work for more than 16 consecutive hours without sleep.[12] If OSHA allows the ACGME to go forward with its proposal to authorize 28-hour shifts for the more than 80,000 U.S. resident physicians beyond their first years of residency training, in wanton disregard of the advice of the IOM and in defiance of the well-founded concerns of the American public,[13] OSHA will be responsible for knowingly endangering both the resident physicians and their patients. There are no data to show that individuals can ‘learn’ to do without sleep or that experience can overcome the detrimental effects of 24 to 28 hours of continuous wakefulness, whereas there are hundreds of laboratory reports showing sleepiness-dependent decrements in performance in adults of the same age as resident physicians. Choosing to apply a 16-hour maximum shift duration limit to interns alone, and justifying the decision by stating that data are only available on interns, is too myopic an application of the science regarding work hours and safety. It is untenable to argue that one day after graduating from internship, a resident physician loses her/his susceptibility to the health and occupational hazards associated with working for 24 to 28 hours straight when a day earlier, according to the same regulations, it was unsafe for the resident physician to do so. Furthermore, scheduling resident physicians to work for 24 to 28 consecutive hours exposes a subset of resident physicians who, for medical or biological reasons, are most vulnerable to the effects of sleep loss. This is an unacceptable risk.[14] As the government entity whose core responsibility is to promote the health and safety of American workers, OSHA has the responsibility to promulgate regulations that will protect the health and safety of resident physicians. ACGME has chosen not to follow this course that the IOM recommended, therefore it is the responsibility of OSHA to step in and provide regulations that will protect these workers.

We also strongly urge that OSHA require a minimum of 10 hours off work between shifts and a minimum of 12 hours off work after a night shift and 48 hours off after a sequence of three- to four-night shifts, as recommended by the IOM. Given the need for commuting and basic activities of daily living, resident physicians provided with only eight hours of time off per night will typically obtain six or fewer hours of sleep, a duration that is suboptimal in its own right, and one that is extremely concerning in a setting in which resident physicians are experiencing recurrent acute sleep deprivation due to ongoing 24+ hour shifts. Given that resident physicians often arrive well before their scheduled shifts to update themselves on their patients and often need to stay longer than their scheduled hours to continue to care for their patients, resident physicians may well have less than four hours of time for sleep on many occasions if the scheduled interval between shifts is only eight hours. With the expectation that resident physicians will be so conscientious, an interval of 10 hours between scheduled shifts is critical; otherwise, resident physicians are placed in the untenable position of having to choose between their work-hour regulations and their patients’ needs. Moreover, at least 12 hours off duty should be required after working the night shift, as recommended by the IOM, given the need to get sufficient recovery sleep after each shift. Even when healthy young adults the age of resident physicians are in a completely dark and quiet environment, when sleep time is scheduled during the circadian daytime, healthy individuals lie awake in bed 20 to 25% of the time due to prominent circadian variations in sleep propensity.[15] Environmental factors such as noise and light further reduce sleep during the daytime.[16] Therefore, more time off after night shifts is required in order for resident physicians to obtain adequate sleep during the daytime, as recognized by the IOM.[17] This was the basis of the IOM recommendation that a minimum of 12 hours off duty be required after night shifts. While 10 hours between shifts is not perfect from a biological perspective, eight hours is certainly inadequate. Insufficient time off between extended shifts very quickly leads to critical vulnerabilities in performance, as chronic sleep deprivation builds, compounding the decrements seen with acute sleep deprivation alone.[18]

Further, resident physicians need one day off per week, but ACGME suggests that days off be averaged over four weeks. Working 12 or 24 days straight can increase fatigue to dangerously high levels. Moreover, working six consecutive night shifts, each of which can be up to 16 hours in duration, can result in the buildup of dangerous levels of cumulative fatigue. The IOM proposed a much safer limit of four consecutive night shifts. The IOM recommended a maximum of four consecutive night shifts given the robust literature from other occupational settings that performance deteriorates with multiple consecutive night shifts. After three to four consecutive nights of work, error and accident rates increase significantly across occupations[19] due to the direct effects of circadian misalignment, and its indirect adverse effects on daytime sleep.[20] With only eight hours off duty between consecutive 16-hour night shifts, resident physicians will only likely sleep four to five hours in the day between shifts. When multiplied over several days, resident physicians will very quickly develop chronic sleep deprivation and reach unsafe levels of sleepiness.[21] [22] There is no reason to believe that this would not hold true for resident physicians. We are very concerned that allowing resident physicians to work six consecutive 16-hour night shifts per week (96 hours/week) for three weeks in a row, which the proposed regulations would allow given the proposed averaging of the 80-hour work week across four weeks, could very well be even more hazardous than the 2003 ACGME regulations. For the ACGME to disregard these risks, after having had the benefit of the comprehensive evidence review conducted by the IOM, represents an enormous missed opportunity to improve both resident physician health and safety and patient care.

B. Compliance

One of the critical reasons for OSHA to assume regulatory control of U.S. residencies is that ACGME is not up to the job. In fact, ACGME has admitted as much — they acknowledge reports suggesting that the “2003 limits did not increase residents’ hours of sleep or reduce fatigue … [and] failed to show that the duty-hour limits had a positive effect on the quality and safety of inpatient care”.[23] By definition, since the rules were intended to accomplish this, the problem is with enforcement. This is a challenging task for several reasons: The ACGME’s monitoring and compliance is based on resident physicians reporting violations in their own programs — but the ACGME does not provide whistleblower protection. Reporting violations hurts the resident physician because a program could be put on probation or lose its accreditation.

In addition, the ACGME cites the “frequency and intensity” of work-hour surveillance required “given the nearly 9,000 accredited programs” as a reason for why its monitoring of hours violations is difficult. Although the ACGME has proposed to monitor the new rules with an annual site visit and compliance report to each “sponsoring institution,” it is unclear how ACGME will accomplish this given the vast number of programs to monitor and its past failures.

Consider two studies that document poor compliance with the ACGME’s 2003 rules. In one study, a confidential, prospective cohort of 4,015 U.S. interns, investigators found that 83.6% of interns reported violations of the ACGME’s 2003 standards during one or more months.[24] Sixty-seven-point-four percent reported working shifts of 30 hours or more. Forty-three percent reported working more than an average of 80 hours per week, even allowing for the ACGME’s practice of permitting averaging of work hours across a four-week period.

In the other study, researchers conducted an intensive prospective cohort study of 220 U.S. pediatric resident physicians to assess changes between the pre- and post-2003 work-hour limits.[25] The results showed no change in resident physicians' frequency of call, in total hours worked, or in total sleep hours. Rates of MVAs, occupational exposures, and depression did not change either.

OSHA must not allow these violations to occur any longer, and given ACGME’s track record and lack of accountability as a private-sector organization, it cannot be counted on to make improvements on its own.

C. Other Countries’ Responses to Excessive Resident Work Hours

While the U.S. has been largely ineffective in seriously addressing the long-work- hour problem, other industrialized countries have taken active and successful steps to regulate resident physician work hours. Indeed, most of the industrialized world already regulates resident physician work hours. Over the past 15 years, legislation, directives, decrees, and collective agreements that limit average weekly hours worked by `resident physicians have been instituted (see Table 2).[26], [27], [28]

Nations that have limited resident physician work hours have done so by designing new approaches to residency programs that emphasize both efficiency and learning. These are implemented by changing shift schedule policies (such as implementing a night float call system, in which rested resident physicians take over the night shift), redefining resident physician duties to include fewer menial tasks, hiring additional ancillary staff, and transferring more workload to faculty physicians. Because they made it a priority, other countries have demonstrated that it is indeed possible for hospitals to schedule reasonable work weeks for their resident physicians.

In the European Union (E.U.), resident physician work hours are regulated through the European Working Time Directive (EWTD).[29] Established in 1993, it was initiated to “promote health and safety at work, given the clear evidence that people who work long hours run higher risks of illness and accidents.” At first, the directive included physicians but not resident physicians. That changed in 2000, and the new rule required all health systems in the E.U. to limit resident physicians to working no more than 48 hours per week, by 2009. Some countries had to transition to the limit, like the United Kingdom (U.K.), while others, like Denmark, were already there. Under these rules, resident physicians also get a minimum of one day off per week.

In the Asia-Pacific region, New Zealand has enforced a maximum work week of 72 hours for resident physicians since 1985.[30] It limits one shift to no more than 16 hours, including call. Resident physicians are also not permitted to work more than 12 days without a 48-hour period of rest.

Enforcement of work hours varies across countries.[31] In the U.K., employers under the National Health Service (NHS) have this responsibility, with compliance monitoring done by the NHS executive and the British Medical Association. In Germany, the government agency responsible for enforcement is the same one responsible for all employee hours, the trade supervisory board. The New Zealand Residents Doctors’ Association negotiates contracts for their members, and enforces these provisions. Because of Australia’s voluntary compliance system, there is no enforcement entity. In Canada, enforcement varies according to province.

Table 1 Work-Hour Regulations in Selected Countries[32]

 

How Hours are Regulated

Maximum Hours Averaged per Week

Maximum Consecutive Hours per Shift

Minimum Rest Hours Between Shifts

Denmark

Legislation and Collective Agreements

37

13-16

 

11

 

El Salvador[33]

NA

Often >120

36

NA

European Union

European Commission and Collective Agreements

48

13

 

11

 

New Zealand

Collective Agreements

72

16

8

United Kingdom

 

European Working Time Directive

48

 

13

 

11

 

In sum, much of the industrialized world has acted to restrict resident physician work hours because of concerns about worker health and patient safety. In many cases, these initiatives have come about through partnerships with state and federal governments. This is in stark contrast to how work-hour changes are made in the United States. There is no government partnership — there is only the ACGME, which is a private, professional entity that is not accountable to the public. The restrictions put in place by these other countries go far beyond what is being considered in the United States. The EU has limited work hours to 48 hours per week and consecutive work hours to 13. New Zealand has similarly limited shifts to 16 consecutive hours since 1985.

D. U.S. Work-Hour Regulations in Other Industries

The federal government has long recognized the importance of government regulation of work hours in the transportation and other industries. Under the jurisdiction of the Department of Transportation (DOT) and its daughter organizations, work-hour limits and rest-period requirements for the highway, aviation, railroad, and maritime industries have been established. The Federal Aviation Administration (FAA) does not allow airline pilots to fly more than 34 hours per week or eight hours in a single day. The Federal Motor Carrier Safety Administration (FMCSA) limits drivers in commercial industries (trucking, bus drivers, etc.) to no more than 11 hours of driving after 10 consecutive hours off duty for property carrying drivers, and 10 hours of driving after eight consecutive hours off duty for passenger carrying drivers.[34] The Federal Railroad Administration (FRA) and the U.S. Coast Guard (USCG) have likewise put work-hour regulations in place for operators in the railroad and maritime industries. These work-hour requirements have been instrumental in maximizing worker and public safety for many years.

In recent years it has become increasingly clear that fatigue plays a major role in transportation safety. A large volume of research designed to further delineate the relationship between fatigue/sleep deprivation and performance/safety has been completed, and more studies are currently underway. Following accident studies conducted in the 1980s, the National Transportation Safety Board (NTSB), the federal agency responsible for investigating significant accidents in transportation, issued a set of recommendations to the DOT in 1989: to investigate fatigue and its relation to safety, to educate transportation industry workers on work and its relation to health, and to revise current hours-of-service regulations to maximize the safety of its workers and the people they serve. The result has been a collaborative effort among organizations within the DOT to “modify the appropriate Codes of Federal Regulations to establish scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.”[35]

As a result of major accident investigations, special investigations, and safety studies that identified operator fatigue as a factor, the NTSB has issued more than 70 fatigue-related safety recommendations to the DOT since their 1989 recommendation. For the fiscal years 1990 through 1998, the DOT spent more than $30 million on fatigue research.[36] OSHA has, to our knowledge, conducted no research on resident physician fatigue, even though work hours of resident physicians greatly exceed the regulated work hours in these other industries.

The Federal Motor Carrier Safety Administration
The National Highway Traffic Safety Administration (NHTSA) estimates that each year, drowsy drivers may be responsible for as many as 103,000 crashes, [37] which result in more than 1,500 fatalities and 71,000 injuries.[38] In the interest of highway safety, the Motor Carrier Act of 1935 resulted in hours-of-service regulations for commercial drivers, based on the rationale that “it is obvious that a man cannot work efficiently or be a safe driver if he does not have an opportunity for approximately 8 hours of sleep in 24.”[39] 

Table 2. Selected Hours-of-Service Regulations in the Department of Transportation.[40]

Occupation

Limits

U.S. Interstate Truck and Bus Drivers : 1938; 1962; 2003; 2005; 2008

 

<11 driving hours within a 14-hour interval

<14 consecutive hours from start to end of work

>8 consecutive rest hours

<60 work hours per 7 days; <70 work hours per 8 days

>34 consecutive hours off between work weeks

U.S. Airplane Pilots (1-2 pilot airplanes): 1950s

 

<8 daily flight hours

<16 daily work hours

>8-12 hours rest required (since 1985)

<34 hours flight time per week

U.S. Railroad Operators: 1907, modified 1969 & 1976 & 1988

 

<12 work hours per day

>8-10 hours rest required per day

 

Research conducted since that time confirms this claim, and has identified the link between sleepiness and crashes, accidents, and errors previously attributed to fatigue and inattention. According to the FMCSA, there is evidence that “many crashes occur as a result of commercial motor vehicle (CMV) driver error, that driver error is often the result of inattention, that inattention can often be the result of fatigue, that the fatigue which causes inattention is often related to sleep deprivation, and that sleep deprivation is often related to working conditions of drivers.”[41] In 1985, the American Automobile Association (AAA) Foundation for

Traffic Safety in “A Report on the Determination and Evaluation of the Role of Fatigue in Heavy Truck Accidents” examined 250 accident reports of heavy-truck accidents in six Western states.[42] The study concluded that fatigue was the probable or primary cause of 41% of those heavy truck accidents. The NTSB’s 1990 study of 182 heavy truck accidents that were fatal to the driver showed that 31% of the accidents in this sample involved fatigue. Fatigue, drugs that are taken to counteract the symptoms of fatigue, drugs that aggravate fatigue, and the interaction of fatigue and drugs were found to be major factors in accident causation.[43]

Another set of studies examined fatigue in terms of the role of continuous service time in causing accidents. In the 1970s, the Federal Highway Administration (FHWA) conducted a study on truck and bus drivers which found that by the maximum-allowed 10 hours of driving time, driver performance deteriorated, driver alertness diminished, rest breaks became less effective, and accident probability increased.[44] Many studies have corroborated the finding that increased service time leads to increased accident risk. A review of a series of truck driver fatigue research studies from the late 1970s to the early 1990s found that time on task appears to have a limited effect on accidents for regular daily work periods less than 11 hours, but may have a more profound impact if the work periods are more than 12 hours.[45] In a survey of 1,000 heavy-goods vehicle drivers undertaken in 1982-1983, the accident risk rate after 11 hours of work was nearly double (1.82 times baseline) that for work periods shorter than 11 hours.[46] Saccomanno et al. found higher overall accident risk associated with 9.5 continuous hours of service or longer compared to baseline.[47] A case-control study including truck crashes in Washington state from June 1984 through July 1986 matched to a comparison sample with similar roadway, time of day, and day of week characteristics, found higher relative risks associated with more than eight hours of driving.[48]

According to a chart published by the FMCSA in the May 2, 2000, Federal Register, a driver runs 16 times the risk of having a fatal accident during the 13th hour of driving than during the first. (See Figure 1.) A study by Lin et al. also described a rising risk curve: the first 4 hours of driving had the lowest accident risk, followed by increases in risk of 50% or more up until the end of the seventh hour, 80% until the eighth hour, and 130% until the ninth hour.[49] In a mini-review by Folkard, it was determined that the safest work-shift duration for commercial drivers is six to nine hours.[50] In terms of weekly service time, a 1996 study by Bowen found that based on a total of 173,110 reported hours of driving time, “it seems that after 80 hours on duty [in an eight-day period], the accident rate rises precipitously.”[51]

Figure 1.


Additional research has identified factors other than continuous driving time as causes of fatigue-related accidents. A 1995 study of 107 accidents (62 of which were fatigue-related) found that the three most important factors that affected fatigue-related accidents were duration of sleep in the last sleep period, the total hours of sleep during the 24 hours prior to the accident, and the presence of split sleep periods. The truck drivers in fatigue-related accidents in this sample had an average of 5.5 hours of sleep in the sleep period prior to the accident, as compared to eight hours for drivers in the non fatigue-related accidents. Many of the truck drivers involved in fatigue-related accidents did not recognize that they were in need of sleep and believed that they were rested when they were not — about 80% rated the quality of their last sleep before the accident as good or excellent. The study concluded that driving at night with a sleep deficit is far more critical in predicting fatigue-related accidents than simply nighttime driving. Moreover, sleep accumulated in short time blocks (split sleep) was found to impede recovery of performance.[52] The sleep characteristics of subjects in this study — decreased sleep in the last sleep period, decreased total hours of sleep in the last 24 hours, and split sleep periods — are all shared by resident physicians under their present working conditions.

Of the different modes of transportation, most data on the relationship between fatigue and safety are available for highway transportation. In the highway transportation industry, research has confirmed the common-sense notion of restricting hours of service, as excessive work schedules have been shown to cause injuries and cost lives. The evidence thus far has been so convincing that driver fatigue was voted the number one safety concern of the FHWA 1995 Truck and Bus Safety Summit, a meeting of over 200 drivers, motor carrier representatives, government officials, and safety advocates.[53]

The Federal Aviation Administration
Aviation work-hour limits were addressed in the Civil Aeronautics Act of 1938 and the Federal Aviation Act of 1958. Depending on the type of domestic flight, pilots may fly no more than 34 hours per week. On domestic flights, the limit is generally eight hours of flying per 24-hour period.[54]

The FAA reports that 21% of the accidents citing errors in the Aviation Safety Reporting System (ASRS) were related to general issues of fatigue.[55] As an example, pilot fatigue is believed to have contributed to the crash of American Airlines Flight 1420, which skidded off the runway of Little Rock (Arkansas) International Airport on June 2, 1999, killing the pilot and 10 others. The accident occurred after the crew had worked more than 13 hours.[56]

In a study entitled, “A Review of Flightcrew-Involved, Major Accidents of the U.S. Air Carriers, 1978 Through 1990,” the NTSB sought to learn more about flight crew performance by evaluating characteristics of the operating environment, crew members, and errors made in major accidents. [57] It found that crews comprising captains and first officers who had been awake longer than the median number of hours of others in their crew position made more errors overall, with significantly more procedural and tactical decision errors.

In 1995, the NTSB examined operator fatigue in its safety studies on flight crew errors, commuter airlines, and aviation safety in Alaska. Under Part 135.261 of the Title 14 Code of Federal Regulations, Alaska is permitted longer flight service hours than the rest of the states, due to its remoteness from the 48 contiguous states. The Board concluded that “the consecutive, long duty days currently permitted [in Alaska] … for commuter airline and air taxi flight crews can contribute to fatigue and are a detriment to safety.”[58]

The Federal Railroad Administration
The Railroad Hours of Service Act was first enacted in 1907, substantially revised in 1969, and amended in 1976 and 1988. In an oral statement at a September 16, 1998 Senate Safety Hearing, Administrator Joline Molitoris of the Federal Railroad Administration (FRA) commented:

Fatigue and the railroad industry have been synonymous for over a hundred years. In some industries, this might be only a quality of life issue. In railroading, it is a life and death safety issue. About one-third of train accidents and many employee injuries and deaths are caused by human factors. We know fatigue underlies many of them. Hundreds of communications from employees and their families eloquently testify to the devastating effects of fatigue…. all employees, contract and management, must be able to work within policies that assure them, their companies and the communities they serve, that they are alert and able to operate safely.[59]

As with the airline industry, freight and passenger rail operations are conducted 24 hours a day, subjecting employees to extensive night work, irregular work schedules, and extended work periods with few or no days off. Fatigue has been thought to be a significant contributing factor to major train accidents in past years. For example, on November 7, 1990, two freight trains collided in Corona, California. The NTSB investigation concluded that “the engineer of train 818 failed to stop his train on the Corona siding at the stop signal because he was asleep or in a microsleep brought about by chronic and acute fatigue … a result of the irregularity and unpredictability of his work schedule.”[60] Another widely publicized example of a fatigue-caused crash was the June 5, 1995 collision of two New York City Transit subway trains on the Williamsburg Bridge in Brooklyn. One person was killed and 69 treated for injuries, with total damages exceeding $2.3 million. The train operator failed to take action to stop his train because he was asleep.[61]

The U.S. Coast Guard
Work-hour regulations for the maritime industry date back to 1908. In 1997, work-hour regulations from the Standards for Training, Certification, and Watch-keeping of the International Maritime Organization (IMO) also became effective.

A 1996 U.S. Coast Guard (USCG) analysis of 279 incidents showed that fatigue contributed to 16% of critical vessel casualties and 33% of personal injuries. [62] Three factors were identified that could be combined to calculate a Fatigue Index score for casualty cases, which could then be used as a predictor for accidents: (1) the number of fatigue symptoms reported by the mariner, (2) the number of hours worked in the 24 hours prior to the casualty, and (3) the number of hours slept in the 24 hours prior to the casualty. These findings parallel those found in commercial driving, demonstrating that the effects of limited sleep apply across different industries.

In a survey of 141 mariners from eight commercial ships (six tankers and two freighters), data on work and sleep patterns as well as other information pertinent to fatigue were collected.[63] The incidence of critical fatigue indicators such as severely restricted sleep durations per 24-hour period, very rapid sleep onset times, and critically low alertness levels suggested that fatigue is a regular occurrence in commercial vessels. The study concluded that sleep disruption, reduced time between watches, fragmented sleep, and long workdays are the principal contributors to the problem.

One of the most high-profile examples of fatigue-related accidents which has compelled the USCG to examine its hours-of-service regulations is the Exxon Valdez oil spill. Ranking among the worst environmental disasters to date, the spill resulted in untold death to wildlife, affected 1300 miles of shoreline, and cost $2.1 billion in clean-up efforts.[64] The three-man crew was held responsible for running the ship aground on Bligh Reef on March 24, 1989. The official NTSB Marine Accident Report states:

The performance of the third mate was deficient, probably because of fatigue, when he assumed supervision of the navigation watch from the master about 2350 [almost midnight]. The third mate’s failure to turn the vessel at the proper time and with sufficient rudder probably was the result of his excessive workload and fatigued condition, which caused him to lose awareness of the location of Bligh Reef. There were no rested deck officers on the Exxon Valdez available to stand the navigation watch when the vessel departed from the Alyeska Terminal.[65]

Relevance of Governmental Regulations in Other Industries to the Health-Care Industry
The justifications for hours-of-service regulations in the transportation industries share many parallels with those in medicine. At the DOT-sponsored Operator Fatigue Management Conference in August of 2000, representatives from all transportation modes agreed that “the incidence of fatigue is underestimated in virtually every transportation mode” and that “it is likely that fatigue is a bigger contributor to incidents, accidents, and fatalities than many realize.”[66] The petitioners believe that this statement applies to resident physicians and their patients as well, for several reasons.

First, as discussed above, workers in the four transportation industries commonly experience long shifts, long weekly hours, irregular shifts, work cycles that do not operate on a 24-hour schedule, and accumulated loss of sleep (sleep debt). Resident physicians experience similar, and in nearly all cases worse, work schedules. Second, research conducted in the different transportation modes has converged on common concepts concerning the roles of duration of continuous service, duration of sleep in the last sleep period, duration of wakefulness since prior sleep, duration of sleep in the last 24 hours, split sleep schedules, and sleep debt, and their relation to human performance and safety. Resident physicians are not exempt from the outcomes predicted by the principles of sleep-wake biology. Third, the efforts of the DOT and the NTSB exemplify the role of the federal government in creating regulations that protect workers and save lives. The commitment to sleep research, implementation of hours-of-service regulations, efforts to revise hours-of-service regulations according to scientific principles, and collaboration with industry and labor, all serve as models for OSHA to follow.

Next page


[1] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. December 15, 2008.

[2] Nasca TJ, Day SH, Amis ES Jr; the ACGME Duty Hour Task Force. The New Recommendations on Duty Hours from the ACGME Task Force. N Engl J Med. 2010 Jun 23

[3] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. December 15, 2008.

[4] Nasca TJ, Day SH, Amis ES Jr; the ACGME Duty Hour Task Force. The New Recommendations on Duty Hours from the ACGME Task Force. N Engl J Med. 2010 Jun 23.

[5] Arnedt JT, Owens J, Crouch M, Stahl J, and Carskadon MA. Neurobehavioral Performance of Residents After Heavy Night Call Vs After Alcohol Ingestion. JAMA. 9-7-2005;294(9):1025-33.

[6] Taffinder NJ, McManus IC, Gul Y, Russell RG, and Darzi A. Effect of Sleep Deprivation on Surgeons' Dexterity on Laparoscopy Simulators. Lancet 1998;352:1191.

[7] Grantcharov TP, Bardram L, Funch-Jensen P, and Rosenberg J. Laparoscopic Performance After One Night on Call in a Surgical Department: Prospective Study. BMJ 2001;323:1222-3.

[8] Eastridge BJ, Hamilton EC, O'Keefe GE, Rege RV, Valentine RJ, Jones DJ, Tesfay S, and Thal ER. Effect of Sleep Deprivation on the Performance of Simulated Laparoscopic Surgical Skill. American Journal of Surgery 2003;186(2):169-74.

[9] Szklo-Coxe M. Are residents' extended shifts associated with adverse events? PLoS Med. 2006 Dec;3(12):e497.

[10] Bhavsar J, Montgomery D, Li J, Kline-Rogers E, Saab F, Motivala A, Froehlich JB, Parekh V, Del Valle J, Eagle KA. Impact of duty hours restrictions on quality of care and clinical outcomes. American Journal of Medicine. 2007;120:968-74.

[11] Horwitz LI, Kosiborod M, Lin Z, Krumholz HM. Changes in outcomes for internal medicine inpatients after work-hour regulations. Annals of Internal Medicine. 2007;147:97-103.

[12] Institute of Medicine. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. National Academies Press, 2009.

[13] Blum AB, Raiszadeh F, Shea S, Mermin D, Lurie P, Landrigan CP, Czeisler CA. U.S. Public Opinion Regarding Proposed Limits on Resident-physician Work Hours. BMC Medicine 2010, 8:33

[14] Czeisler CA. Medical and genetic differences in the adverse impact of sleep loss on performance: ethical considerations for the medical profession. Trans Am Clin Climatol Assoc 2009; 120:249-285

[15] Dijk DJ, Czeisler CA. Contribution of the circadian pacemaker and the sleephomeostat to sleep propensity, sleep structure, electroencephalographic slowwaves, and sleep spindle activity in humans. J Neurosci. 1995 May;15(5 Pt 1):3526-38.

[16] Akerstedt T. Shift work and disturbed sleep/wakefulness. Occup Med (Lond). 2003 Mar;53(2):89-94. Review.

[17] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[18] Cohen DA, Wang W, Wyatt JK, Kronauer RE, Dijk D, Czeisler CA, Klerman EB. Uncovering residual effects of chronic sleep loss on human performance. Science Translational Medicine 2010;2(14):14ra3.

[19] Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and "accidents". Am J Ind Med 2006.

[20] Åkerstedt, T., Torsvall, L., and Gillberg, M. Sleep-Wake Disturbances in Shift Work:Implications of Sleep Loss and Circadian Rhythms. Sleep Research 1983;12:359.

[21] Van Dongen HPA, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003; 26:117-126.

[22] Belenky G, Wesenstein NJ, Thorne DR, Thomas ML, Sing HC, Redmond D P Russo MB, Balkin TJ. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: A sleep dose-response study. J Sleep Res 2003; 12:1-12

[23] Nasca TJ, Day SH, Amis ES Jr; the ACGME Duty Hour Task Force. The New Recommendations on Duty Hours from the ACGME Task Force. N Engl J Med. 2010 Jun 23.

[24] Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA. 2006 Sep 6;296(9):1063-70.

[25] Chang VY, Arora V. Effects of the accreditation council for graduate medical education duty-hour limits on sleep, work hours, and safety. Pediatrics. 2008 Dec;122(6):1413-4; author reply 1414-5.

[26] Sharfstein JM. Asleep on the job. The New Republic. June 21, 1999:17.

[27] Australian Medical Association. AMA safe hours campaign. http://www.domino.ama.com.au/dir0103/IRRemun.nsf/96ec31299990db634a2568e700217720?OpenView

[28] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[29] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[30] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[31] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[32] Institute of Medicine. Resident duty hours: enhancing sleep, supervision, and safety. National Acadamies Press, 2009.

[33] Czeisler CA. Medical and genetic differences in the adverse impact of sleep loss on performance: ethical considerations for the medical profession. Trans Am Clin Climatol Assoc. 2009;120:249-85. Review.

[34] “Hours of Service Regulations”. US Department of Transportation Federal Motor Carrier Safety Administration. Web. Accessed August 25, 2010.

[35] National Transportation Safety Board. NTSB Safety Recommendation A-99-45, as cited in National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[36] National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[37] Knipling, RR, Wang JS. October 1995. Revised estimates of the U.S. drowsy driver crash problem size based on general estimates system case reviews. In: 39th Annual Proceedings, Association for the Advancement of Automotive Medicine, Chicago, IL. October 16–18, 1995.

[38] National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[39] Federal Register, Vol. 65, No. 85, May 2, 2000, pp. 25540-25611.

[40] Czeisler CA. Ethical considerations for the scheduling of work in continuous operations: Physicians in training as a case study. In: Cappuccio F, Miller M, Lockley SW, eds. Sleep Epidemiology – from aetiology to public health. Oxford: Oxford University Press. In press.

[41] Federal Register, Vol. 65, No. 85, May 2, 2000, pp. 25540-25611.

[42] AAA Foundation for Auto Safety. A report on the determination and evaluation of the role of fatigue in heavy truck accidents. October 1985.

[43] National Transportation Safety Board. Fatigue, alcohol, other drugs, and medical factors in fatal-to-the-driver heavy truck crashes. Safety Study NTSB/SS-90/01 and NTSB/SS-90/02. Washington, DC. February 1990, p. 70.

[44] Harris W, Mackie RR, et al. A study of the relationships among fatigue, hours of service, and safety of operations of truck and bus drivers. Human Factors Research, Inc. (Springfield, VA, National Technical Information Service, November 1972 [PB-213 963]).

[45] Brown, ID. Driver fatigue. Human Factors 1994;36(2): 298-314.

[46] Hamelin P. Lorry drivers’ time habits in work and their involvement in traffic accidents. Ergonomics 1987;30(9):1323-1333.

[47] Saccomanno FF, Shortreed JH, and Yu M. Effect of driver fatigue on commercial vehicle accidents. [Truck Safety: Perceptions and Reality. Waterloo, Ontario: Institute for Risk Research, University of Waterloo. 1996] pp. 157-174.

[48] Jones IS, Stein HS. Effect of driver hours of service on tractor-trailer crash involvement. Arlington, VA: Insurance Institute of Highway Safety. September 1987.

[49] Lin TD, Jovanis PP, Yang CZ. Time of day models of motor carrier accident risk. Transportation Research Record 1467. Washington, DC: Transportation Research Board. 1994;1-8.

[50] Folkard S. “Time on shift” effects in safety: a mini-review. Shiftwork International Newsletter 1995;12(1):16.

[51] Bowen V. Utility service vehicle study. Richmond, VA: University of Richmond. August 1996. (FHWA docket number FHWA-97-2350-82)

[52] National Transportation Safety Board. Factors that affect fatigue in heavy truck accidents. Safety Study NTSB/SS-95/01 and NTSB/SS-95/02. Washington, DC. 1995.

[53] Federal Register, Vol. 65, No. 85, May 2,2000, pp. 25540-25611.

[54] “Fact Sheet”. Federal Aviation Administration. January 27, 2010. Web. Accessed August 25, 2010.

[55] Federal Register, Vol. 60, No. 244, December 20, 1995.

[56] Airlines unveil plan to reduce pilot fatigue. http://www.cnn.com/2000/TRAVEL/NEWS/09/13/pilot.fatigue/index.html

[57] National Transportation Safety Board. A review of flightcrew-involved, major accidents of U.S. air carriers, 1978 through 1990. Safety Study NTSB/SS-94/01. Washington, DC. 1994.

[58] National Transportation Safety Board. Aviation safety in Alaska. Safety Study NTSB/SS-95/03. Washington, DC. 1995

[59] Oral statement of Administrator Joline Molitoris for Senate Safety Hearing. September 16, 1998.

[60] National Transportation Safety Board. NTSB Railroad Accident Report, Atchison, Topeka and Santa Fe Railway Company (ATSF) freight trains ATSF 818 and ATSF 891 on the ATSF railway, Corona, CA, November 7, 1990. August 23, 1991, as cited in National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[61] National Transportation Safety Board. NTSB Railroad Accident Report, collision involving two New York City subway trains on the Williamsburg Bridge in Brooklyn, NY, June 5, 1995. September 11, 1996, as cited in National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[62] McCallum, MC, Raby, M, Rothblum,AM. Procedures for investigating and reporting human factors and fatigue contributions to marine casualties. CG-D-09-97. U.S. Department of Transportation, U.S. Coast Guard, Marine Safety and Environmental Protection. Washington, DC. 1996.

[63] US Coast Guard. Fatigue and alertness in merchant marine personnel: a field study of work and sleep patterns. US Coast Guard Research and Development Center, Groton, CT. Accession No. AD-A322126. June 1996.

[64] Exxon Valdez Oil Spill Trustee Council. http://www.oilspill.state.ak.us/history/history.htm

[65] National Transportation Safety Board. NTSB marine accident report, grounding of the U.S. Tankship Exxon Valdez on Bligh Reef, Prince William Sound near Valdez, Alaska, March 24, 1989, September 18, 1990, as cited in National Transportation Safety Board. Evaluation of U.S. Department of Transportation efforts in the 1990s to address operator fatigue. Safety Report NTSB/SR-99/01. May 1999.

[66] Department of Transportation. Conference summary, partnering for transportation safety: human-centered systems: operator fatigue management. Tysons Corner, VA. August 29-30, 2000. http://scitech.dot.gov/reeng/humperf.humperf.html

Copyright © 2014 Public Citizen. Some rights reserved. Non-commercial use of text and images in which Public Citizen holds the copyright is permitted, with attribution, under the terms and conditions of a Creative Commons License. This Web site is shared by Public Citizen Inc. and Public Citizen Foundation. Learn More about the distinction between these two components of Public Citizen.


Public Citizen, Inc. and Public Citizen Foundation

 

Together, two separate corporate entities called Public Citizen, Inc. and Public Citizen Foundation, Inc., form Public Citizen. Both entities are part of the same overall organization, and this Web site refers to the two organizations collectively as Public Citizen.

Although the work of the two components overlaps, some activities are done by one component and not the other. The primary distinction is with respect to lobbying activity. Public Citizen, Inc., an IRS § 501(c)(4) entity, lobbies Congress to advance Public Citizen’s mission of protecting public health and safety, advancing government transparency, and urging corporate accountability. Public Citizen Foundation, however, is an IRS § 501(c)(3) organization. Accordingly, its ability to engage in lobbying is limited by federal law, but it may receive donations that are tax-deductible by the contributor. Public Citizen Inc. does most of the lobbying activity discussed on the Public Citizen Web site. Public Citizen Foundation performs most of the litigation and education activities discussed on the Web site.

You may make a contribution to Public Citizen, Inc., Public Citizen Foundation, or both. Contributions to both organizations are used to support our public interest work. However, each Public Citizen component will use only the funds contributed directly to it to carry out the activities it conducts as part of Public Citizen’s mission. Only gifts to the Foundation are tax-deductible. Individuals who want to join Public Citizen should make a contribution to Public Citizen, Inc., which will not be tax deductible.

 

To become a member of Public Citizen, click here.
To become a member and make an additional tax-deductible donation to Public Citizen Foundation, click here.