The European Working Time Directive Regulations The European Working Time Directive (EWTD) was first introduced for all European workers in 1993. Beginning in 2004, these regulations began applying to doctors throughout Europe, including both junior doctors and senior doctors. Currently, weekly limits in the United Kingdom and other European nations vary from 48-58 hours; by 2009, however, all physicians will be limited to a maximum of 48 hours per week. These regulations are considerably more restrictive than ACGME regulations in the US. Key provisions of the EWTD are as follows:
Scheduling for the EWTD in the United Kingdom In the United Kingdom, there has been strong interest in testing pilot programs that find creative solutions to the work hours limits imposed in the EWTD. The National Health Service in the UK has supported initiatives such as the “Hospital at Night” program to try to reallocate workload at night in a manner that optimizes distribution of resources. Good data regarding the effects of the EWTD in general, the Hospital at Night program in particular, or other initiatives are lacking however. Objectively measured work hours, sleep, patient safety, and resident safety, education, and quality of life are needed across a range of attempted initiatives to make evidence-based decisions regarding optimal scheduling structures, rosters, and proposed intervention plans. The Royal College of Physicians (RCP) organized a multidisciplinary working group, headed by Nicholas Horrocks and Roy Pounder to examine the challenges surrounding scheduling within the EWTD limits (2006). This group used circadian based principles to devise schedules to meet the EWTD requirements. There are two schedules that this group recommends over all other options (Schedule A and Schedule B). Both schedules use 10 doctors in each rotation over a 10 week period, because the group found it impossible to schedule fewer doctors and meet the EWTD requirements while also satisfying the needs of a typical hospital unit. Schedule A is the optimal schedule recommended by this group. Schedule B is the next best schedule and varies only in weekend coverage from Schedule A. |
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These schedules are devised so that the doctors working the solid black shifts are considered the primary admitting physicians, while the doctors working the hatched shifts may have clinic or specialty duties. The doctors working the hatched shifts may work any 9 hours as long as it is within the day or evening hours. While the EWTD recommendations allow for scheduling 13 hour shifts, the RCP working group recommends shorter duration shifts in order to allow flexibility on each schedule. A hospital in the UK will incur a fine each time a physician breaks a work rule and scheduling up to the maximum time on shift does not allow for a doctor to remain at work when needed. By recommending 9 hour work shifts for the admitting physicians, there is flexibility and overlap in each schedule. None of the schedules recommended by the RCP working group have been rigorously tested; however, the group did run a Fatigue Index assessment using a tool devised to evaluate industry shift work schedules. Using this index they found these two schedules to be the safest out of all options they devised. These schedules both have an advantage over the HWHHSG schedule in that all shifts are shorter than 13 hours. These schedules also have clear lifestyle advantages. Rather than having fairly random days off as in the US, these schedules rotate so that most days off occur over the weekends. The problems with this schedule are clearly disruption of continuity of care and time for sign out. Implementation of these schedules means that every three days a new doctor is introduced with primary admitting responsibilities and scheduled hand off is limited to between 30 and 60 minutes. |