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De Martino RR, Brewster LP, Kokkosis AA, Glass C, Boros M, Kreishman P, Kauvar DA, Farber A. The perspective of the vascular surgery trainee on new ACGME regulations, fatigue, resident training, and patient safety. Vasc Endovascular Surg 2012; 45:697-702. [PMID: 22262113 DOI: 10.1177/1538574411418130] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the opinions of vascular surgery trainees on the new Accreditation Council for Graduate Medical Education (ACGME) guidelines. METHODS A questionnaire was developed and electronically distributed to trainee members of the Society for Vascular Surgery. RESULTS Of 238 eligible vascular trainees, 38 (16%) participated. Respondents were predominantly 30 to 35 years of age (47%), male (69%), in 2-year fellowship (73%), and at large academic centers (61%). Trainees report occasionally working while fatigued (63%). Fellows were more likely to report for duty while fatigued (P = .012) than integrated vascular residents. Respondents thought further work-hour restrictions would not improve patient care or training (P < .05) and may not lead to more sleep or improved quality of life. Respondents reported that duty hours should vary by specialty (81%) and allow flexibility in the last years of training (P < .05). CONCLUSIONS Vascular surgery trainees are concerned about further duty-hour restrictions on patient care, education, and training and fatigue mitigation has to be balanced against the need to adequately train vascular surgeons.
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Affiliation(s)
- Randall R De Martino
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
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Tan P, Hogle NJ, Widmann WD. Limiting PGY 1 residents to 16 hours of duty: review and report of a workshop. JOURNAL OF SURGICAL EDUCATION 2012; 69:355-359. [PMID: 22483138 DOI: 10.1016/j.jsurg.2011.10.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Revised: 09/20/2011] [Accepted: 10/27/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted limits on duty hours. Residents were restricted to working 80 hours/week and limited to 24 hours of continuous patient care. Effective July 2011, an additional restriction will be instituted for PGY 1 residents limiting continuous duty to 16 hours maximum. OBJECTIVE Prospective evaluation of the impact of the upcoming work shift limitations for PGY 1 residents. DESIGN/SETTING/PARTICIPANTS Review of literature and discussions among program directors, program coordinators, and residents on the effects of prior limitations of duty hours, as a point of reference, to manage the changes of duty hours for PGY 1 residents during a workshop at the Association of Program Directors in Surgery Annual Meeting. RESULTS Work-hour restrictions necessitate a change from the traditional 24-hour on-duty call schedule for PGY 1 residents. The benefits to patients of being treated by less tired doctors working in shifts may be offset by communication failures from poor handoffs, rendering the system prone to adverse events/near misses. With additional work-hour restrictions, it is imperative to anticipate problems and deal with them effectively. Continued reevaluation of the handoff system and efforts made to decrease the number of preventable adverse events that typically occur during periods of cross coverage should be undertaken. Labor costs to carry out these new restrictions are predictably high but can be made budget neutral if improvement in patient care leads to reduction in the costs of corrective actions. CONCLUSIONS Residency programs have adapted to the 2003 work-hour restrictions without apparent ill effect. We must study the effects of the July 2011 requirements prospectively as the traditional frontline physicians (PGY 1 residents) will no longer be available for 24-hour duty shifts.
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Affiliation(s)
- Pamela Tan
- Department of Surgery, Staten Island University Hospital, Staten Island, New York, USA
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Yu H, Greenberg MD, Haviland AM, Farley DO. Multiple Patient Safety Events Within a Single Hospitalization. Am J Med Qual 2012; 27:472-9. [DOI: 10.1177/1062860612441052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hao Yu
- RAND Corporation, Pittsburgh, PA
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Sudarshan M, Hanna WC, Jamal MH, Nguyen LHP, Fraser SA. Are Canadian general surgery residents ready for the 80-hour work week? A nationwide survey. Can J Surg 2012; 55:53-7. [PMID: 22269303 DOI: 10.1503/cjs.019110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The purpose of this study was to describe Canadian general surgery residents' perceptions regarding potential implementation of work-hour restrictions. METHODS An ethics review board-approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, operative exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents' responses. RESULTS Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75-100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed (p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24-hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed (p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of residents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51%juniors, p = 0.26) agreed with the adoption of the 80-hour work week. CONCLUSION There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.
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Decision making in urological surgery. Int Urol Nephrol 2012; 44:701-10. [DOI: 10.1007/s11255-011-0101-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 11/25/2011] [Indexed: 01/09/2023]
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Downey JR, Hernandez-Boussard T, Banka G, Morton JM. Is patient safety improving? National trends in patient safety indicators: 1998-2007. Health Serv Res 2012; 47:414-30. [PMID: 22150789 PMCID: PMC3393002 DOI: 10.1111/j.1475-6773.2011.01361.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
CONTEXT Emphasis has been placed on quality and patient safety in medicine; however, little is known about whether quality over time has actually improved in areas such as patient safety indicators (PSIs). OBJECTIVE To determine whether national trends for hospital PSIs have improved from 1998 to 2007. DESIGN, SETTING, AND PARTICIPANTS Using PSI criteria from the Agency for Healthcare Research and Quality, PSIs were identified in the Nationwide Inpatient Sample (NIS) for all eligible inpatient admissions between 1998 and 2007. Joinpoint regression was used to estimate annual percentage changes (APCs) for PSIs. MAIN OUTCOME MEASURE Annual percent change for PSIs. RESULTS From 1998 to 2007, 7.6 million PSI events occurred for over 69 million hospitalizations. A total of 14 PSIs showed statistically significant trends. Seven PSIs had increasing APC: postoperative pulmonary embolism or deep vein thrombosis (8.94), postoperative physiological or metabolic derangement (7.67), postoperative sepsis (7.17), selected infections due to medical care (4.05), decubitus ulcer (3.05), accidental puncture or laceration (2.64), and postoperative respiratory failure (1.46). Seven PSIs showed decreasing APCs: birth trauma injury to neonate (-17.79), failure to rescue (-6.05), postoperative hip fracture (-5.86), obstetric trauma-vaginal without instrument (-5.69), obstetric trauma-vaginal with instrument (-4.11), iatrogenic pneumothorax (-2.5), and postoperative wound dehiscence (-1.8). CONCLUSION This is the first study to establish national trends of PSIs during the past decade indicating areas for potential quality improvement prioritization. While many factors influence these trends, the results indicate opportunities for either emulation or elimination of current patient safety trends.
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Affiliation(s)
- John R Downey
- Department of Radiology, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. A Review of Patient Safety Measures Based on Routinely Collected Hospital Data. Am J Med Qual 2011; 27:154-69. [DOI: 10.1177/1062860611414697] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carmen Tsang
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | - William Palmer
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- National Audit Office, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
| | | | - Paul Aylin
- Dr Foster Unit at Imperial College, Imperial College, London, UK
- Imperial Centre for Patient Safety and Service Quality, London, UK
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Clark CJ, Sindell SL, Koehler RP. Template for success: using a resident-designed sign-out template in the handover of patient care. JOURNAL OF SURGICAL EDUCATION 2011; 68:52-57. [PMID: 21292216 DOI: 10.1016/j.jsurg.2010.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/12/2010] [Accepted: 09/02/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Report our implementation of a standardized handover process in a general surgery residency program. DESIGN The standardized handover process, sign-out template, method of implementation, and continuous quality improvement process were designed by general surgery residents with support of faculty and senior hospital administration using standard work principles and business models of the Virginia Mason Production System and the Toyota Production System. SETTING Nonprofit, tertiary referral teaching hospital. PARTICIPANTS General surgery residents, residency faculty, patient care providers, and hospital administration. RESULTS After instruction in quality improvement initiatives, a team of general surgery residents designed a sign-out process using an electronic template and standard procedures. The initial implementation phase resulted in 73% compliance. Using resident-driven continuous quality improvement processes, real-time feedback enabled residents to modify and improve this process, eventually attaining 100% compliance and acceptance by residents. CONCLUSIONS The creation of a standardized template and protocol for patient handovers might eliminate communication failures. Encouraging residents to participate in this process can establish the groundwork for successful implementation of a standardized handover process. Integrating a continuous quality-improvement process into such an initiative can promote active participation of busy general surgery residents and lead to successful implementation of standard procedures.
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Affiliation(s)
- Clancy J Clark
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington 98101, USA.
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Bell EF, Hansen NI, Morriss FH, Stoll BJ, Ambalavanan N, Gould JB, Laptook AR, Walsh MC, Carlo WA, Shankaran S, Das A, Higgins RD. Impact of timing of birth and resident duty-hour restrictions on outcomes for small preterm infants. Pediatrics 2010; 126:222-31. [PMID: 20643715 PMCID: PMC2924191 DOI: 10.1542/peds.2010-0456] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The goal was to examine the impact of birth at night, on the weekend, and during July or August (the first months of the academic year) and the impact of resident duty-hour restrictions on mortality and morbidity rates for very low birth weight infants. METHODS Outcomes were analyzed for 11,137 infants with birth weights of 501 to 1250 g who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry in 2001-2005. Approximately one-half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessments at 18 to 22 months were completed for 4508 infants. Mortality rate, short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth. RESULTS There was no effect of the timing of birth on mortality rate and no impact on the risks of short-term morbidities except that the risk of retinopathy of prematurity (stage > or =2) was higher after the introduction of duty-hour restrictions and the risk of retinopathy of prematurity requiring operative treatment was lower for infants born during the late night than during the day. There was no impact of the timing of birth on neurodevelopmental outcome except that the risk of hearing impairment or death was slightly lower among infants born in July or August. CONCLUSION In this network, the timing of birth had little effect on the risks of death and morbidity for very low birth weight infants, which suggests that staffing patterns were adequate to provide consistent care.
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Affiliation(s)
- Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | | | | | | | | | - Jeffrey B. Gould
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Abhik Das
- RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med 2010; 38:S83-9. [PMID: 20502179 DOI: 10.1097/ccm.0b013e3181dd8364] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in diagnostic tests, technological interventions, and pharmacotherapy have resulted in spectacular results for many intensive care unit (ICU) patients who, in earlier generations, would have succumbed to their critical illness. At the same time, the complexity and intensity of care required for ICU patients is also associated with greater risks for harm resulting from care. As in other inpatient areas, medications are the most common type of therapy in ICUs and are also associated with the most frequent type of ICU adverse events. Critically ill patients are at high risk for adverse drug events for many reasons, including the complexity of their disease that creates challenges in drug dosing, their vulnerability to rapid changes in pharmacotherapy, the intensive care environment providing ample distractions and opportunity for error, the administration of complex drug regimens, the numerous high-alert medications that they receive, and the mode of drug administration. The clinical outcomes of adverse drug events can result in end-organ damage and even death. The costs of an adverse drug event can be substantial to healthcare systems with an additional $6,000-$9,000 for each event. The multiprofessional patient care team is one approach to promoting patient safety in the ICU.
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The Impact of the 80-Hour Work Week on Appropriate Resident Case Coverage. J Surg Res 2010; 162:33-6. [DOI: 10.1016/j.jss.2009.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 11/25/2009] [Accepted: 12/02/2009] [Indexed: 11/23/2022]
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Todd SR, Fahy BN, Paukert JL, Mersinger D, Johnson ML, Bass BL. How accurate are self-reported resident duty hours? JOURNAL OF SURGICAL EDUCATION 2010; 67:103-107. [PMID: 20656607 DOI: 10.1016/j.jsurg.2009.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Revised: 08/02/2009] [Accepted: 08/04/2009] [Indexed: 05/29/2023]
Abstract
PURPOSE The Methodist Hospital monitors resident duty hours using self-report for external rotations and an electronic time clock system for internal rotations where residents use their identification badges to "swipe in and out." This study was conducted to compare the accuracy of self-reports against the electronic system. METHODS This was a prospective observational study. For 1 month, surgical residents in an academic training program self-reported their duty hours and used the electronic system. The primary outcome measure was the accuracy of self-reported duty hours. RESULTS Twenty two surgical residents accounted for 450 individual duty-hour periods. Sixty-four percent of the residents were men, and the distribution by postgraduate year (PGY) was PGY1 27%, PGY2 27%, PGY3 14%, PGY4 14%, and PGY5 18%. The number of missing duty-hour period reports was significantly greater for self-reports (44/450) than for the electronic system (18/450), p < 0.001. There were no statistically significant differences between either reporting method in regard to total number of duty-hour violations and individual duty-hour violations. CONCLUSION Self-report was as accurate as the electronic system in determining the occurrence of duty-hour violations. Because residents may be able to manipulate reporting in both systems, the possibility of inaccuracies exists.
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Affiliation(s)
- S Rob Todd
- Department of Surgery, The Methodist Hospital, Weill Cornell Medical College, Houston, Texas 77030, USA.
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Abstract
BACKGROUND Resident duty hour reforms of 2003 had the potential to create a major impact on the delivery of inpatient care. OBJECTIVE We examine whether the reforms influenced the probability of a patient experiencing a prolonged hospital length of stay (PLOS), a measure reflecting either inefficiency of care or the development of complications that may slow the rate of discharge. RESEARCH DESIGN Conditional logistic models to compare PLOS in more versus less teaching-intensive hospitals before and after the reform, adjusting for patient comorbidities, common time trends, and hospital site. SUBJECTS Medicare (N = 6,059,015) and Veterans Affairs (VA) (N = 210,276) patients admitted for medical conditions (acute myocardial infarction, heart failure, stroke, or gastrointestinal bleeding) or surgical procedures (general, orthopedic, and vascular) from July 2000 to June 2005. MEASURES Prolonged length of stay. RESULTS Modeling all medical conditions together, the odds of prolonged stay in the first year post reform at more versus less teaching intensive hospitals was 1.01 (95% CI: 0.97-1.05) for Medicare and 1.07 (0.94-1.20) for the VA. Results were similarly negative in the second year post reform. For "combined surgery" the post year 1 odds ratios were 1.04 (0.98-1.09) and 0.94 (0.78-1.14) for Medicare and the VA respectively, and similarly unchanged in post year 2. Isolated increases in the probability of prolonged stay did occur for some vascular surgery procedures. CONCLUSIONS Hospitals generally found ways to cope with duty hour reform without increasing the prevalence of prolonged hospital stays, a marker of either inefficient care or complications.
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Gopaldas RR, Huh J, Bakaeen FG, Wang XL, Coselli JS, LeMaire SA, Chu D. The Impact of Resident Work-Hour Restrictions on Outcomes of Cardiac Operations. J Surg Res 2009; 157:268-74. [DOI: 10.1016/j.jss.2009.03.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 03/04/2009] [Accepted: 03/26/2009] [Indexed: 11/28/2022]
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Rivard PE, Elixhauser A, Christiansen CL, Shibei Zhao, Rosen AK. Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals. Med Care Res Rev 2009; 67:321-41. [PMID: 19880671 DOI: 10.1177/1077558709347378] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study tested the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients' case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study's findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.
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Lewis FR. Comment of the American Board of Surgery on the recommendations of the Institute of Medicine Report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety". Surgery 2009; 146:410-9. [PMID: 19715796 DOI: 10.1016/j.surg.2009.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 07/09/2009] [Indexed: 11/18/2022]
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Britt L, Sachdeva AK, Healy GB, Whalen TV, Blair PG. Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: A response from the American College of Surgeons to the Report of the Institute of Medicine, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”. Surgery 2009; 146:398-409. [DOI: 10.1016/j.surg.2009.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 07/09/2009] [Indexed: 11/27/2022]
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Yu H, Greenberg MD, Haviland AM, Farley DO. “Canary Measures” Among the AHRQ Patient Safety Indicators. Am J Med Qual 2009; 24:465-73. [DOI: 10.1177/1062860609341585] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hao Yu
- RAND Corporation, Pittsburgh, Pennsylvania,
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Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. ACTA ACUST UNITED AC 2009; 67:173-8; discussion 178-9. [PMID: 19590331 DOI: 10.1097/ta.0b013e31819ea514] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable. METHODS All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable. RESULTS Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns. CONCLUSION RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.
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Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients. Med Care 2009; 47:723-31. [PMID: 19536029 DOI: 10.1097/mlr.0b013e31819a588f] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Improving patient safety was a strong motivation behind duty hour regulations implemented by Accreditation Council for Graduate Medical Education on July 1, 2003. We investigated whether rates of patient safety indicators (PSIs) changed after these reforms. RESEARCH DESIGN Observational study of patients admitted to Veterans Health Administration (VA) (N = 826,047) and Medicare (N = 13,367,273) acute-care hospitals from July 1, 2000 to June 30, 2005. We examined changes in patient safety events in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform, using conditional logistic regression, adjusting for patient age, gender, comorbidities, secular trends, baseline severity, and hospital site. MEASURES Ten PSIs were aggregated into 3 composite measures based on factor analyses: "Continuity of Care," "Technical Care," and "Other" composites. RESULTS Continuity of Care composite rates showed no significant changes postreform in hospitals of different teaching intensity in either VA or Medicare. In the VA, there were no significant changes postreform for the technical care composite. In Medicare, the odds of a Technical Care PSI event in more versus less teaching-intensive hospitals in postreform year 1 were 1.12 (95% CI; 1.01-1.25); there were no significant relative changes in postreform year 2. Other composite rates increased in VA in postreform year 2 in more versus less teaching-intensive hospitals (odds ratio, 1.63; 95% CI; 1.10-2.41), but not in Medicare in either postreform year. CONCLUSIONS Duty hour reform had no systematic impact on PSI rates. In the few cases where there were statistically significant increases in the relative odds of developing a PSI, the magnitude of the absolute increases were too small to be clinically meaningful.
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Bates DW. Fatigue, Resident Work Hours, and Safety. Med Care 2009; 47:711-3. [DOI: 10.1097/mlr.0b013e3181adc2b9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effects of resident work-hour restrictions on orthopaedic education and patient care. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e328316640a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Curet MJ. Resident Work Hour Restrictions: Where Are We Now? J Am Coll Surg 2008; 207:767-76. [DOI: 10.1016/j.jamcollsurg.2008.07.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Revised: 07/15/2008] [Accepted: 07/17/2008] [Indexed: 10/21/2022]
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Schenarts PJ, Phade SV, Goettler CE, Waibel BH, Agle SC, Bard MR, Rotondo MF. Impact of Acute Care General Surgery Coverage by Trauma Surgeons on the Trauma Patient. Am Surg 2008. [DOI: 10.1177/000313480807400607] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days ( P < 0.0001), intensive care unit length of stay ( P < 0.0001), and hospital length of stay ( P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.
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Affiliation(s)
- Paul J. Schenarts
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Sachin V. Phade
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Claudia E. Goettler
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Brett H. Waibel
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Steven C. Agle
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Michael R. Bard
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Michael F. Rotondo
- From the Department of Surgery, East Carolina University, Greenville, North Carolina
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76
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Cao CGL, Weinger MB, Slagle J, Zhou C, Ou J, Gillin S, Sheh B, Mazzei W. Differences in day and night shift clinical performance in anesthesiology. HUMAN FACTORS 2008; 50:276-290. [PMID: 18516838 DOI: 10.1518/001872008x288303] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE This study examined whether anesthesia residents (physicians in training) performed clinical duties in the operating room differently during the day versus at night. BACKGROUND Fatigue from sleep deprivation and working through the night is common for physicians, particularly during residency training. METHODS Using a repeated-measures design, we studied 13 pairs of day-night matched anesthesia cases. Dependent measures included task times, workload ratings, response to an alarm light latency task, and mood. RESULTS Residents spent significantly less time on manual tasks and more time on monitoring tasks during the maintenance phase at night than during the day. Residents reported more negative mood at night than during the day, both pre- and postoperation. However, time of day had no effect on the mood change between pre- and postoperation. Workload ratings and the response time to an alarm light latency task were not significantly different between night and day cases. CONCLUSIONS Because night shift residents had been awake and working for more than 16 hr, the observed differences in task performance and mood may be attributed to fatigue. The changes in task distribution during night shift work may represent compensatory strategies to maintain patient care quality while keeping perceived workload at a manageable level. APPLICATIONS Fatigue effects during night shifts should be considered when designing work-rest schedules for clinicians. This matched-case control scheme can also be applied to study other phenomena associated with patient safety in the actual clinical environment.
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Affiliation(s)
- Caroline G L Cao
- School of Engineering, Tufts University, Medford, Massachusetts, USA
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78
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Woods SE, Zabat E, Talen MR, Bishop S, Stephens L, Engel A. Residents' perspective on the impact of the 80-hour workweek policy. TEACHING AND LEARNING IN MEDICINE 2008; 20:131-135. [PMID: 18444199 DOI: 10.1080/10401330801991584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND The 80-hour workweek was initiated in 2003 to reduce the resident workweek and subsequently improve the safety and quality of patient care. PURPOSE The purpose is to assess the impact of the 80-hr workweek from a resident's perspective. METHOD We surveyed residents with experience before and after the 80-hr workweek policy. The survey assessed residents' perspective on the impact of the 80-hr workweek on 4 areas: patient care/safety, training experience, resident team functioning, and personal life. RESULTS There were 111 respondents (57% female, 65% married, average age = 32 years, 66% primary care residents). We found the 80-hr workweek had the greatest impact in personal self-care and sleep hygiene. Primary care residents reported a significantly more positive impact of the 80-hr workweek on quality of the training compared to specialty residents. There was no difference between the primary care residents and specialty residents for patient care/safety, resident team functioning, and personal life. Gender, marital status, and having children did not impact how residents' evaluated the 80-hr workweek. CONCLUSION Residents, with pre- and post-80-hr workweek experience, reported the policy change as having the greatest benefit on their self-care and personal life significantly more than any other area.
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Affiliation(s)
- Scott E Woods
- Bethesda Family Medicine Residency, Cincinnati, Ohio 45212, USA.
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79
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Horinouchi H, Tokuda Y, Nishimura N, Terai M, Takahashi O, Ohde S, Ishikawa R, Fukui T. Influence of Residents' Workload, Mental State and Job Satisfaction on Procedural Error : a prospective daily questionnaire-based study. ACTA ACUST UNITED AC 2008. [DOI: 10.14442/general.9.57] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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80
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Hearld LR, Alexander JA, Fraser I, Jiang HJ. Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods. Med Care Res Rev 2007; 65:259-99. [PMID: 18089769 DOI: 10.1177/1077558707309613] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.
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Affiliation(s)
- Larry R Hearld
- University of Michigan School of Public Health, Ann Arbor
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81
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Abstract
Surgeons' intraoperative decision making is a key element of clinical practice, yet has received scant attention in the surgical literature. In recent years, serial changes in the configuration of surgical training in the UK have reduced the time spent by trainees in the operating theatre. The opportunity to replace this lost experience with active teaching of decision making is important, but there seem to have been very few studies that have directly examined the cognitive skills underlying surgical decision making during operations. From the available evidence in surgery, and drawing from research in other safety-critical occupations, four decision-making strategies that surgeons may use are discussed: intuitive (recognition-primed), rule based, option comparison and creative. Surgeons' decision-making processes should be studied to provide a better evidence base for the training of cognitive skills for the intraoperative environment.
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Affiliation(s)
- Rhona Flin
- School of Psychology, University of Aberdeen, Aberdeen, UK.
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82
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Bates T, Cecil E, Greene I. The effect of the EWTD on training in general surgery: an analysis of electronic logbook records. ACTA ACUST UNITED AC 2007. [DOI: 10.1308/147363507x177045] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The introduction of time-limited surgical training in the UK in 1994 following the Calman report raised concerns over the hands-on experience of trainees, heightened by the hours reduction demanded by the New Deal. From 1994, junior doctors' on-duty hours of work for hard-pressed posts were targeted to a limit of 56 hours but SpRs were allowed a voluntary extension from 73 on-duty hours to a maximum of 83 hours per week. By 1995 concern was being expressed at the reduction in training time and continuity of patient care and although calls for more targeted training were made, evidence of a negative impact on training has continued to surface.
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Affiliation(s)
- T Bates
- the Breast Unit, William Harvey Hospital, Ashford, Kent
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83
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Carpenter RO, Spooner J, Arbogast PG, Tarpley JL, Griffin MR, Lomis KD. Work Hours Restrictions as an Ethical Dilemma for Residents: A Descriptive Survey of Violation Types and Frequency. ACTA ACUST UNITED AC 2006; 63:448-55. [DOI: 10.1016/j.cursur.2006.06.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 06/07/2006] [Accepted: 06/12/2006] [Indexed: 11/16/2022]
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Lockley SW, Landrigan CP, Barger LK, Czeisler CA. When policy meets physiology: the challenge of reducing resident work hours. Clin Orthop Relat Res 2006; 449:116-27. [PMID: 16770285 DOI: 10.1097/01.blo.0000224057.32367.84] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Considerable controversy exists regarding optimal work hours for physicians and surgeons in training. In a series of studies, we assessed the effect of extended work hours on resident sleep and health as well as patient safety. In a validated nationwide survey, we found that residents who had worked 24 hours or longer were 2.3 times more likely to have a motor vehicle crash following that shift than when they worked < 24 hours, and that the monthly risk of a crash increased by 16.2% after each extended duration shift. We also found in a randomized trial that interns working a traditional on-call schedule slept 5.8 hours less per week, had twice as many attentional failures on duty overnight, and made 36% more serious medical errors and nearly six times more serious diagnostic errors than when working on a schedule that limited continuous duty to 16 hours. While numerous opinions have been published opposing reductions in extended work hours due to concerns regarding continuity of patient care, reduced educational opportunities, and traditionally-defined professionalism, there are remarkably few objective data in support of continuing to schedule medical trainees to work shifts > 24 hours. An evidence-based approach is needed to minimize the well-documented risk that current work hour practices confer on resident health and patient safety while optimizing education and continuity of care.
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Affiliation(s)
- Steven W Lockley
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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85
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Peyre SE, Peyre CG, Sullivan ME, Towfigh S. A Surgical Skills Elective Can Improve Student Confidence Prior to Internship. J Surg Res 2006; 133:11-5. [PMID: 16580692 DOI: 10.1016/j.jss.2006.02.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 02/09/2006] [Accepted: 02/13/2006] [Indexed: 01/22/2023]
Abstract
BACKGROUND A focused surgical resident readiness curriculum for senior medical students can improve confidence in surgical skills compared to current surgical interns. MATERIALS AND METHODS A 3-week surgical skills lab elective enrolled senior medical students applying to surgical residency programs, with the purpose of improving surgical skills and easing anxiety prior to surgical internship. Students were surveyed before and after the elective regarding their confidence in performing 21 skills covered by the curriculum. A similar confidence survey was administered to the incoming surgical intern class. Interns were also surveyed regarding prior skills lab instruction during medical school. Statistical analyses included Student's paired t-test and two-way analysis of variance. RESULTS Six medical students and 23 interns were surveyed. All medical students significantly improved their confidence by the end of the resident readiness curriculum (P = 0.0004). Although students initially had lower confidence than surgical interns in performing surgical skills and in their knowledge of anatomy prior to the course, their confidence after the course was significantly higher than that of the incoming surgical interns (P = 0.035). Surgical interns with prior skills lab experience in their medical school reported higher confidence than those who did not have a skills lab experience (P = 0.019). Among all subgroups, medical students with skills lab experience had the highest confidence score, followed by interns with previous skills lab experience, then by interns with no previous skills lab experience, and last, by medical student with no skills lab experience. CONCLUSION Surgical interns often feel unprepared to perform skills necessary for residency. A focused skills lab elective during medical school can bridge the gap and improve confidence prior to internship.
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Affiliation(s)
- Sarah E Peyre
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 90089-9202, USA
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86
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Nauta RJ. Five Uneasy Peaces: Perfect Storm Meets Professional Autonomy in Surgical Education. J Am Coll Surg 2006; 202:953-66. [PMID: 16735211 DOI: 10.1016/j.jamcollsurg.2006.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 02/21/2006] [Accepted: 02/21/2006] [Indexed: 01/13/2023]
Affiliation(s)
- Russell J Nauta
- Department of Surgery, Harvard Medical School, Boston, MA, USA
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87
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Affiliation(s)
- Bruce G Wolff
- Division of Colon Rectal Surgery, Mayo Foundation, 200 First Street SW, Rochester, Minnesota 55905, USA.
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88
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Carpenter RO, Austin MT, Tarpley JL, Griffin MR, Lomis KD. Work-hour restrictions as an ethical dilemma for residents. Am J Surg 2006; 191:527-32. [PMID: 16531148 DOI: 10.1016/j.amjsurg.2006.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Revised: 01/05/2006] [Accepted: 01/05/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND We propose that the standardized work-hour limitations have created an ethical dilemma for residents. METHODS A survey tool was designed to assess factors that influence the number of hours residents work and report. The program directors of pediatrics, internal medicine, and general surgery at our institution supported their residents' participation. A voluntary, anonymous survey of these residents was performed. RESULTS One hundred seventy of 265 eligible residents were surveyed. Eighty-one percent of residents surveyed responded. Eighty percent of respondents reported exceeding work-hour restrictions at least once within the past 6 months. The factor of greatest influence measured was concern for patient care (80%). Forty-nine percent of respondents admitted underreporting their work hours. CONCLUSIONS The Accreditation Council for Graduate Medical Education work-hour restrictions have created an ethical dilemma for residents. Our data show that a significant number of residents feel compelled to exceed work-hour regulations and report those hours falsely.
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Affiliation(s)
- Robert O Carpenter
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA.
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89
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Abstract
In July 2003, work-hour restrictions were implemented by the Accreditation Council for Graduate Medical Education (ACGME) to limit resident duty hours. Attending surgeon work-hours have not been similarly reduced, and many trauma services have added emergency general surgery responsibilities. We hypothesized that trauma attending/resident work-hour disparity may disincentivize residents from selecting trauma careers and that trauma directors would view ACGME regulations negatively. We conducted a 6-month study of resident and in-house trauma attending self-reported hours at a level I trauma center and sent a questionnaire to 172 national level I trauma directors (TDs) regarding work-hours restrictions. TD survey response rate was 48 per cent; 100 per cent of 15 residents and 6 trauma faculty completed work-hour logs. Attending mean hours (87.1/ wk), monthly calls (5), and shifts >30 hours exceeded that of all resident groups. Case volume was similar. Residents viewed their lifestyle more favorably than the lifestyle of the trauma attending (Likert score 3.6 ± 0.5 vs Likert score 2.5 ± 0.8, P = 0.0003). Seventy-one per cent cited attending work hours and lifestyle as a reason not to pursue a trauma career. Nationally, 80 per cent of trauma surgeons cover emergency general surgery; 40 per cent work greater than 80 hours weekly, compared with <1 per cent of surgical trainees (P < 0.0001). Most TDs feel that residents do not spend more time reading (89%) or operating (96%); 68 per cent feel patient care has suffered as a result of duty-hours restrictions. Seventy-one per cent feel residents will not select trauma surgery as a career as a result of changes in duty hours. Perceived trauma attending/resident work-hour disparity may disincentive trainees from trauma career selection. TDs view resident duty-hour restrictions negatively.
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