Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

The Association Between Resident Physician Work-Hour Regulations and Physician Safety and Health

BACKGROUND

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-h limit on consecutive hours for first-year resident physicians. We sought to examine the effect of these work-hour regulations on physician safety.

METHODS

All medical students matched to a US residency program from 2002 to 2007 and 2014 to 2017 were invited to participate in prospective cohort studies. Each month participants reported hours of work, extended duration shifts, and adverse safety outcomes, including motor vehicle crashes, percutaneous injuries, and attentional failures. The incidence of each outcome was compared before and after the 2011 ACGME work-hour limit. Hypotheses were tested using generalized linear models adjusted for potential confounders.

RESULTS

Of all first-year resident physicians nationwide, 13% participated in the study, with 80,266 monthly reports completed by 15,276 first-year resident physicians. Following implementation of the 16-h 2011 ACGME work-hour limit, the mean number of extended duration (≥24-h) shifts per month decreased from 3.9 to 0.2. The risk of motor vehicle crash decreased 24% (relative risk [RR] 0.76; 0.67-0.85), percutaneous injury risk decreased more than 40% (relative risk 0.54; 0.48-0.61), and the rate of attentional failures was reduced 18% (incidence rate ratio [IRR] 0.82; 0.78-0.86). Extended duration shifts and prolonged weekly work hours were associated with an increased risk of adverse safety outcomes independent of cohort.

CONCLUSIONS

The 2011 ACGME work-hour limit was associated with meaningful improvements in physician safety and health. Surveillance is needed to monitor the ongoing impact of work hours on physician safety, health, and well-being.

Physicians' working time restriction and its impact on patient safety: an integrative review

BACKGROUND

Although shift work is a part of the physicians' routine, there is controversy on the length of shifts and adequate rest for safe professional practice. If on the one hand long working hours might have negative impact on patient safety by interfering with the psychological and physical functioning of physicians, on the other shorter working hours might impair the safety of patients due to interference with the continuity of care.

OBJECTIVE

To analyze the impact of restrictions to physicians' working hours on patient safety.

METHOD

Integrative literature review in which we surveyed studies on restriction to physicians' working time and patient safety included in databases National Library of Medicine (PubMed) and Scientific Electronic Library Online (SciELO) until May 2018. Thirty-five studies which met the inclusion criteria were included.

RESULTS

Patient safety outcomes analyzed in the included studies were mortality, adverse events, continuity of care, in-hospital complications, readmission rate and length of stay at hospital. Restriction to working time was associated with variable impact on patient safety indicators, but often did not modify their performance.

CONCLUSION

Restrictions to physicians' working time did not always improved patient safety indicators. Focusing on interventions which only seek to limit the workload of physicians might be insufficient to bring consistent improvement to patient care.

Does Patient Experience Predict 30-Day Readmission? A Patient-Level Analysis of HCAHPS Data

BACKGROUND

Hospital-level studies have found an inverse relationship between patient experience and readmissions. However, based on typical survey response time, it is unclear if patients are able to respond to surveys before they get readmitted and whether being readmitted might be a driver of poor experience scores (reverse causation).

OBJECTIVE

Using patient-level Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) and Press Ganey data to examine the relationship between readmissions and experience scores and to distinguish between patients who responded before or after a subsequent readmission.

DESIGN

Retrospective analysis of 10-year HCAHPS data.

SETTING

Single tertiary care academic hospital.

PARTICIPANTS

Patients readmitted within 30 days of an index hospitalization who received an HCAHPS survey linked to index admission comprised the exposure group. This group was divided into those who responded prior to readmission and those who responded after readmission. Nonreadmitted patients comprised the control group.

ANALYSIS

Multivariable-logistic regression to analyze the association between HCHAPS and Press Ganey scores and 30-readmission status, adjusted for patient factors.

RESULTS

Only 15.8% of the readmitted patients responded to the survey prior to readmission, and their scores were not significantly different from the nonreadmitted patients. The patients who responded after readmission were significantly more dissatisfied with physicians (doctors listened 73.0% vs 79.2%, aOR 0.75, P < .0001), staff responsiveness, (call button 50.0% vs 59.1%, aOR 0.71, P < .0001) pain control, discharge plan, noise, and cleanliness of the hospital.

CONCLUSIONS

Our findings suggest that poor patient experience may be due to being readmitted, rather than being predictive of readmission.

A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision

Objective

Monitoring the supervision of residents can be a challenging task. We describe our experience with the implementation of a templated note system for documenting procedures with the aim of enabling automated, discrete, and standardized capture of documentation of supervision of residents performing floor-based procedures, with minimal extra effort from the residents.

Materials and methods

Procedural note templates were designed using the standard existing template within a commercial electronic health record software. Templates for common procedures were created such that residents could document every procedure performed outside of the formal procedural areas. Automated reports were generated and letters were sent to noncompliers.

Results

A total of 27 045 inpatient non-formal procedural area procedures were recorded from August 2012 to June 2014. Compliance with NoteWriter template usage averaged 86% in the first year and increased to 94.6% in the second year ( P  = .0055).

Initially, only 12.5% of residents documented supervision of any form. By the end of the first year, this was above 80%, with the gains maintained into the second year and beyond. Direct supervision was documented to have occurred where required in 62.8% in the first year and increased to 99.8% in the second year ( P  = .0001) after the addition of hard stops. Notification of attendings prior to procedures was documented 100% of the time by September 2013. Letters sent to errant residents decreased from 3.6 to 0.83 per 100 residents per week.

Conclusion

The templated procedure note system with hard stops and integrated reporting can successfully be used to improve monitoring of resident supervision. This has potential impact on resident education and patient safety.

Effect of a Handover Tool on Efficiency of Care and Mortality for Interhospital Transfers

BACKGROUND

Interhospital transfer is frequent, and transferred patients experience delays in the provision of care and higher mortality rates when compared to patients directly admitted. The interhospital handover is a key opportunity to improve care but has not been evaluated.

OBJECTIVE

To determine the effect of a universal handover tool on timeliness of care, length of stay (LOS), and mortality among interhospital transfer patients.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort of patients transferred to an academic medical center between July 1, 2009 and December 31, 2010 with interrupted time-series design.

INTERVENTION

One-page handover tool containing information critical for immediate patient care instituted hospital-wide on July 1, 2010. The handover tool was completed by the transferring physician and available for review before patient arrival.

MEASUREMENTS

Time-to-admission order entry, LOS after transfer, in-hospital mortality.

RESULTS

There was no significant change in the time-to-admission order entry after implementation (47 minutes vs. 45 minutes, adjusted P = 0.94). There was a nonstatistically significant reduction in LOS after implementation (6.5 days vs. 5.8 days, adjusted P = 0.06). In-hospital mortality for transfer patients declined significantly in the postintervention period from 12.0% to 8.9% (adjusted odds ratio, 0.68; 95% confidence interval, 0.47 - 0.99, P = 0.04). There was no change in mortality for the concurrent control group.

CONCLUSION

Implementation of a standardized handover tool for interhospital transfer was feasible and may be associated with significant reductions in length of stay and mortality. Widespread adoption of similar tools may improve outcomes in this high-risk population. Journal of Hospital Medicine 2017;12:23-28.

Impact of extended duty hours on medical trainees

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.

Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules

BACKGROUND

Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre.

METHODS

We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009).

RESULTS

A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions.

CONCLUSION

We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.

Quality and Safety in Orthopaedics: Learning and Teaching at the Same Time: AOA Critical Issues

Increasing attention has been placed on providing higher quality and safer patient care. This requires the development of a new set of competencies to better understand and navigate the system and lead the orthopaedic team. While still trying to learn and develop these competencies, the academic orthopaedist is also expected to model and teach them.The orthopaedic surgeon must understand what is being measured and why, both for purposes of providing better care and to eliminate unnecessary expense in the system. Metrics currently include hospital-acquired conditions, "never events," and thirty-day readmission rates. More will undoubtedly follow.Although commitment and excellence at the individual level are essential, the orthopaedist must think at the systems level to provide the highest value of care. A work culture characterized by respect and trust is essential to improved communication, teamwork, and confidential peer review. An increasing number of resources, both in print and electronic format, are available for us to understand what we can do now to improve quality and safety.Resident education in quality and safety is a fundamental component of the systems-based practice competency, the Next Accreditation System, and the Clinical Learning Environment Review. This needs to be longitudinally integrated into the curriculum and applied parallel to the development of resident knowledge and skill, and will be best learned if resident learning is experiential and taught within a genuine culture of quality and safety.

The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review

BACKGROUND

Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents still is unclear. Advocates interpret the research as necessitating immediate change; opponents draw competing conclusions.

OBJECTIVE

This study updates a systematic review of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education's 2011 regulations.

METHODS

The review draws on reports catalogued in MEDLINE and PreMEDLINE from 2010 to 2013. Interventions that dealt with the duty hour restrictions included night float, shortened shifts, and protected time for sleep. Outcomes were patient care, resident well-being, and resident education. Studies were excluded if they were not conducted in patient care settings.

RESULTS

Twenty-seven studies met the inclusion criteria. Most frequently, the studies concluded that the restrictions had no impact on patient care (50%) or resident wellness (47%), and had a negative impact on resident education (64%). Night float was the most frequent means of implementing duty hour restrictions, yet it yielded the highest proportion of unfavorable findings.

CONCLUSIONS

This updated review, including 27 recent applicable studies, demonstrates that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education. New approaches to the issue of physician fatigue and its relationship to patient care and resident education are needed.

Characterization of a handoff documentation tool through usage log data

Handoffs are a critical component of coordinated patient care; however, poor handoffs have been associated with near misses and adverse events. To address this, national agencies have recommended standardizing handoffs, for example through the use of handoff documentation tools. Recent research suggests that handoff tools, typically designed for physicians, are often used by non-physician providers as information sources. In this study, we investigated patterns of edits of an electronic handoff tool in a large teaching hospital through examination of its usage log data. Qualitative interviews with clinicians were used to triangulate log data findings. The analysis showed that despite its primary focus on facilitating transitions of care, information in the handoff documentation tool was updated throughout the day. Interviews with residents confirmed that they purposefully updated information to make it available for other members of their patient care teams. This further reiterates the view of electronic handoff tools as facilitators of team communication and coordination. However, the study also showed considerable variability in the frequency of updates between different units and across different patients. Further research is required to understand what factors drive such diversity in the use of electronic handoff tool and whether this diversity can be used to make inferences about patients' conditions.

The effect of duty hour regulation on resident surgical case volume in otolaryngology

OBJECTIVE

Evaluate the effect of duty hour regulation on graduating otolaryngology resident surgical case volume and analyze trends in surgical case volume for Accreditation Council for Graduate Medical Education (ACGME) key indicator cases from 1996 to 2011.

STUDY DESIGN

Time-trend analysis of surgical case volume.

SETTING

Nationwide sample of otolaryngology residency programs.

SUBJECTS

Operative logs from the American Board of Otolaryngology and ACGME for otolaryngology residents graduating in the years 1996 to 2011.

METHODS

Key indicator volumes and grouped domain volumes before and after resident duty hour regulations (2003) were calculated and compared. Independent t test was performed to evaluate overall difference in operative volume. Wilcoxon rank sum test evaluated differences between procedures per time period. Linear regression evaluated trend.

RESULTS

The average total number of key indicator cases per graduating resident was 440.8 in 1996-2003 compared to 500.4 cases in 2004-2011, and overall average per number of key indicators was 31.5 and 36.2, respectively (P = .067). Four key indicator cases showed statistically significant (P < .05) increases in volume after duty hour implementation. General/pediatrics was the only grouped domain to show a significant increase. In contrast, the rate of change in operative volume decreased post duty hour for only 2 key indicators (P < .05). The year-by-year trend in average operative volume showed significant increases for 5 key indicator cases (P < .05).

CONCLUSION

Implementation of the 2003 duty hour regulations has not reduced total volume of key indicator cases for graduating otolaryngology residents. The overall trend in operative volume is increasing for several specific key indicators.

Resident work hours: why keeping the status quo may not be such a bad thing

Resident duty hours have become an increasingly debated topic in post-graduate medical education. Work-hour restrictions have been implemented for first-year residents in the US and more recently for all residents in Quebec. Current and future work-hour rules affect a variety of stakeholders: government, hospitals, residency training programs, patients, and most of all residents. In this article, we hope to examine the issue from a Canadian perspective and delineate some of the reasons why changing the current call structure may have potentially deleterious effects to all those concerned.