Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial

JAMA Intern Med. 2013 Apr 22;173(8):649-55. doi: 10.1001/jamainternmed.2013.2973.


Importance: On July 1, 2011, the Accreditation Council for Graduate Medical Education implemented further restrictions of its 2003 regulations on duty hours and supervision. It remains unclear if the 2003 regulations improved trainee well-being or patient safety.

Objective: To determine the effects of the 2011 Accreditation Council for Graduate Medical Education duty hour regulations compared with the 2003 regulations concerning sleep duration, trainee education, continuity of patient care, and perceived quality of care among internal medicine trainees.

Design and setting: Crossover study design in an academic research setting.

Participants: Medical house staff.

Intervention: General medical teams were randomly assigned using a sealed-envelope draw to an experimental model or a control model.

Main outcome measures: We randomly assigned 4 medical house staff teams (43 interns) using a 3-month crossover design to a 2003-compliant model of every fourth night overnight call (control) with 30-hour duty limits or to one of two 2011-compliant models of every fifth night overnight call (Q5) or a night float schedule (NF), both with 16-hour duty limits. We measured sleep duration using actigraphy and used admission volumes, educational opportunities, the number of handoffs, and satisfaction surveys to assess trainee education, continuity of patient care, and perceived quality of care. RESULTS The study included 560 control, 420 Q5, and 140 NF days that interns worked and 834 hospital admissions. Compared with controls, interns on NF slept longer during the on call period (mean, 5.1 vs 8.3 hours; P = .003), and interns on Q5 slept longer during the postcall period (mean, 7.5 vs 10.2 hours; P = .05). However, both the Q5 and NF models increased handoffs, decreased availability for teaching conferences, and reduced intern presence during daytime work hours. Residents and nurses in both experimental models perceived reduced quality of care, so much so with NF that it was terminated early.

Conclusions and relevance: Compared with a 2003-compliant model, two 2011 duty hour regulation-compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Accreditation
  • Adult
  • Continuity of Patient Care / standards*
  • Cross-Over Studies
  • Female
  • Humans
  • Internal Medicine / education*
  • Internal Medicine / standards
  • Internship and Residency / standards*
  • Male
  • Personnel Staffing and Scheduling / standards
  • Quality of Health Care / standards*
  • Sleep*
  • Work Schedule Tolerance*