I came across yet another interesting article today while searching on the Internet for something else that was completely unrelated (funny how that happens quite a lot!). According to an article published in September, 2017 (okay, it's a little old, but still relevant) in the Navy Times, the United States Navy has issued new rules and guidelines dictating the amount of time that sailors can stand watch, as well as the amount of time that sailors are required to rest between watches. The new rules and guidelines are designed to better align watch schedules and shipboard routines while at sea with sailors' circadian rhythms and sleep-wake cycles. The new rules were issued following an investigation into the fatal collisions of the USS John S. McCain and USS Fitzgerald in the summer of 2017, which cited fatigue as one of the contributing factors to both accidents.
Perhaps I should step back and explain a little more about what it means to "stand watch" in the Navy. There is a long tradition, going back to the Golden Age of Sail, that proscribed how the work of sailing a ship was distributed among the officers and crew. Every member of the crew was assigned to a "watch" - typically, the crew was divided into two (e.g., Port and Starboard watches) or three (e.g., Red, White, and Blue watches) watches. The 24 hour day was then divided into the following watches (this time referring to a period of time, typically a 4 hour period):
First watch: 2000 to 0000 (military time is used here, but this refers to 8 PM to midnight)
Middle watch: 0000 to 0400
Morning watch: 0400 to 0800
Forenoon watch: 0800 to 1200
Afternoon watch: 1200 to 1600
First dog watch: 1600 to 1800
Last dog watch: 1800 to 2000
Note that all but two of the watches lasted 4 hours - the two exceptions, the first and last dog watch, were shortened to two hours so that there were an odd number of watches in the day. In this manner, the crew could rotate through all the watches, rather than one half of the crew always having to be on duty for the Middle watch every night, as an example. In addition, the crew would eat their evening meal during the two dog watches. There are a number of reasons why the two shortened watch periods are called "dog watches," which I won't get in to here (but if you are interested, see here).
While there have been a number of variations on the watch system used over the years, they are all essentially the same from a conceptual standpoint. All of the different watch schedules did have one thing in common - they resulted in a significant number of hours of work in a given week. Government studies found that, in some cases, sailors on ships were working more than 100 hours a week. Notably, the Navy already limited the number of hours that aviation crews and submarine crews could work in a given 24 hour period or over the course of a week.
The new watch standards are in direct response to these two very high profile accidents. When asked about the accident investigations, Admiral John Richardson, the Chief Naval Officer, said, "Both of these accidents were preventable and the respective investigations found multiple failures by watch standers that contributed to the incidents. We must do better."
Rather than dictating the exact schedule, commanding officers of each ship will be allowed some discretion to choose from several watch schedules in order to accommodate for a ship's crew level, deployment status, and operational mission. The point, however, is that they will have to abide by certain requirements. Naval Surface Warfare spokesman, Cmdr. John Perkins said, "You're going to have to form some level of watch bill that protects sailors' sleep. The ships still have some flexibility, but sailors are going to have to get a certain amount of protected sleep."
The preceding discussion sounds very familiar to those of us in health care. Several years ago, the Accreditation Council for Graduate Medical Education, which oversees and dictates how resident physicians are trained in the United States, issued restrictions on how long interns and residents could work in the hospital, largely in response to concerns that physician fatigue was impacting patient safety. All of this makes perfect sense - we don't want physicians and nurses making mistakes because they are so tired that they "can't think straight." Unfortunately, there is not a lot of evidence to support that duty hour restrictions translate to significant improvements in patient outcomes (for example, see the systematic review here and here and here). In fact, several authors have expressed concern that duty hour restrictions can lead to worse outcomes by virtue of the fact that the number of hand-offs in care from one physician to another is increased. Important information pertinent to patient care is frequently lost during these hand-offs of care.
Let me be clear. I do support duty hour restrictions - tired physicians and nurses do make mistakes, and we should not ask them to work the kinds of hours that we used to require in the past. However, there are two points that I would like to make. First, simple fixes often do not result in significant improvements, especially in complex systems like health care and shipboard duty. Any system-level change needs to be done very carefully and only after trying to identify and mitigate the unintended consequences of such a chance (for example, increasing the number of hand-offs in care). Second, something that has become quite obvious to me over time is that health care is not that much different from other industries. We have a lot to learn from one another. For example, perhaps the Navy could learn about the impact of duty hour restrictions from the health care industry? We need to share our experiences and our best practices. That is the only way that we will get better.
No comments:
Post a Comment