Don't cross duty hours

Always choose a hospital which has good technology and good employee policies.

Junior doctors are often exploited in most medical institutions, especially the private ones, all over the world. The exploitation is rampant in India. Many studies off late have shown that more patients die during the night time and on holidays.

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A recent report from Colorado-based health care inc. has shown that as many as 1,95,000 people in a year could be dying in US hospitals because of easily preventable errors. One of the main preventable errors is the long duty hours. The same is true for the nurses.

Duty hours are defined by the Accreditation Council for Graduate Medical Education (ACGME) as all the clinical activities related to the residency programme that includes patient care, both in-patients and out-patients, administrative duties related to patients' care, the provision for transfer of patient care, time spent in house during on-call activities and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent from the duty site.

According to international guidelines junior doctor's work week must not exceed 80 hours averaged over four weeks period inclusive of call.

After every seven days duty they must get one day off. One day is defined as one continuous 24-hour period free of all clinical, educational and administrative activities.

In-house call is to be no more frequent than every third night averaged over a four-week period. There must be 10-hour period provided between all daily duty periods and after in-house call.

Continuous on-site duty including in-house call must not exceed 24 consecutive hours. However, residents may remain on duty for up to six additional hours to participate in didactic activities, personal care of patients, conduct out-patient clinics and maintain continuity of medical and surgical care. No new patient may be accepted after 24 hours of continuous hours of duty. 

In US there are one lac medical residents and in India over 1.5 lac residents at any given time. They are the backbone of any patient care. All over the world, Asian doctors, to earn more money, have a habit of joining extra duties on weekends called moonlighting hours. The same has now been included in the 80 hours workload. 

The international guidelines also restrict doing continuous duty in intensive care areas and emergency units continuously for 12 hours. 

In house call is defined as those duty hours beyond normal week day when residents are required to be immediately available in the assigned institutions.

A recent survey in US has shown that nurses at US hospitals for about 40 per cent of the time are working wrong shifts that raise the risk of medical mistakes such as giving the wrong medication or the wrong dose.

According to a study published in the Journal of Health Affairs in July 2004, the likelihood of a hospital nurse making a mistake was three times higher once the shift stretched past 12.5 hours. The study was led by researchers at the University of Pennsylvania. 

According to the study one who works more than 40 hours per week or works unscheduled overtime is likely to make more errors. According to their suggestions, routine use of 12-hour shifts should be curtailed and overtime especially if associated with 12-hour shift should be eliminated.

In India, many private hospitals may be engaging B or C grade nurses who are not completely qualified. If such nurses are made to work long hours the error rate is likely to be very high. Most junior doctors in India doing a residency programme accept jobs with the intention of financial survival but their mind is always in preparation for a PG. When the mind is not 100 per cent in patient's care, the mistakes are likely to be higher. Many junior doctors for earning more money work double shifts - one in a government hospital and one in a private hospital or in a small nursing home. Double duty invariably ends up in making more mistakes.

But not all hospitals are like that. One can find a mix of medical establishments in the Asian countries. Some adhere to international guidelines and some do not.

When choosing a hospital in India it is advisable to choose one which has not only good technology but also good employee policies. Most of the newer hospitals today are adhering to the international guidelines regarding work policies.

(Dr. Aggarwal is President, Heart Care Foundation of India, Deputy Dean, Board of Medical Education, Moolchand Hospital and President Elect, Delhi Medical Association.)