Impact of duty hours restrictions on quality of care and clinical outcomes

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.

Transition to a Night Float System in Ophthalmology Residency: Perceptions of Resident Wellness and Performance

Purpose The purpose of this study is to characterize the influence of a new night float rotation on resident wellness and performance in the Duke University Eye Center Ophthalmology Residency Program.

Methods We analyzed three classes of ophthalmology residents: one class (n = 4) utilized the new night float rotation with no daytime clinical duties, while two senior classes (n = 12) utilized the traditional call system wherein they had daytime and nighttime responsibilities. Residents completed a questionnaire regarding their perceptions of the night float rotation. Supervising attendings (n = 15) were also surveyed about their perceptions of the new rotation.

Results Zero of the four residents on the night float rotation reported burnout compared with 6 of 11 residents in the traditional call system. Most residents supported the adoption of the night float rotation, but this trend was less apparent among fellows and attendings.

Most respondents believed the new night float rotation reduced burnout, fatigue, and work hours while increasing time for nonclinical activities. Perceived skills gained while on call were felt to be similar between the two call systems. Fellows and attendings believed residents in the night float system performed similarly or better than residents in the traditional system in indicators such as knowledge and enthusiasm. There was no significant difference in the average number of patient encounters (290.8 ± 30.5 vs. 310.7 ± 25.4, p = 0.163), phone encounters (430.8 ± 20.2 vs. 357.1 ± 90.0, p = 0.068), or average hours worked per week (57.3 ± 4.6 vs. 58.0 ± 5.7 p = 0.797) per resident between night float residents and traditional call residents.

Conclusions This study shows resident support for a night float rotation in ophthalmology residency at Duke, with reductions in burnout and more time for nonclinical activities without affecting perceived clinical performance. We hope this study serves as an impetus for other ophthalmology programs considering a transition to a night float system.

The Academic Impact of Advanced Clinical Fellowship Training among General Thoracic Surgeons

OBJECTIVE

Advanced clinical fellowship training has become a popular option for surgical trainees seeking to bolster their clinical training and expertise. However, the long-term academic impact of this additional training following a traditional thoracic surgery fellowship is unknown. This study aimed to delineate the impact of an advanced clinical fellowship on subsequent research productivity and advancement in academic career among general thoracic surgeons.

METHODS

Using an internally constructed database of active, academic general thoracic surgeons who are current faculty at accredited cardiothoracic surgery training programs within the United States, surgeons were dichotomized according to whether an advanced clinical fellowship was completed or not. Academic career metrics measured by research productivity, scholarly impact (H-index), funding by the National Institutes of Health, and academic rank were compared.

RESULTS

Among 285 general thoracic surgeons, 89 (31.2%) underwent an advanced fellowship, whereas 196 (68.8%) did not complete an advanced fellowship. The most commonly pursued advanced fellowship was minimally invasive thoracic surgery (32.0%). There were no differences between the two groups in terms of gender, international medical training, or postgraduate education. Those who completed an advanced clinical fellowship were less likely to have completed a dedicated research fellowship compared to those who had not completed any additional clinical training (58.4% vs. 74.0%, p = 0.0124). Surgeons completing an advanced clinical fellowship demonstrated similar cumulative first-author publications (p = 0.4572), last-author publications (p = 0.7855), H-index (p = 0.9651), National Institutes of Health funding (p = 0.7540), and years needed to advance to associate professor (p = 0.3410) or full rank professor (p = 0.1545) compared to surgeons who did not complete an advanced fellowship. These findings persisted in sub-analyses controlling for surgeons completing a dedicated research fellowship.

CONCLUSIONS

Academic general thoracic surgeons completing an advanced clinical fellowship demonstrate similar research output and ascend the academic ladder at a similar pace as those not pursuing additional training.

Hospital nurse shift length, patient-centered care, and the perceived quality and patient safety

BACKGROUND

There is no clear evidence that can guide decision makers regarding the appropriate shift length in the hospitals in Malaysia. Further, there is no study that explored the value of patient-centered care of nurses working longer shifts and its impact on the care outcomes.

OBJECTIVE

The study aims to investigate the effect of the hospital nurse shift length and patient-centered care on the perceived quality and safety of nurses in the medical-surgical and multidisciplinary wards in Malaysia.

METHODS

A cross-sectional survey has been conducted on 12 hospitals in Malaysia. Data have been collected via a questionnaire. A stratified sampling has been used. The Hayes macro regression analyses have been used to examine the mediating effects of patient-centered care between the effect of working long shifts on the perceived quality and patient safety.

RESULTS

There is a significant mediation effect of patient-centered care between the effect of shift length on the perceived quality (F = 42.90, P ˂ 0.001) and patient safety (F = 25.12, P ˂ 0.001).

CONCLUSION

Patient-centered care mitigates the effect of the shift length on the care outcomes. The study provides an input for the policymakers that patient-centered care and restructuring duty hours are important to provide high-quality patient care.

Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review

BACKGROUND

This study comprehensively reviewed the literature on the impact of shorter versus longer shifts on critical and important outcomes for Emergency Medical Services (EMS) personnel and related shift worker groups.

METHODS

Six databases (e.g., PubMed/MEDLINE) were searched, including one website. This search was guided by a research question developed by an expert panel a priori and registered with the PROSPERO database of systematic reviews (2016:CRD42016040099). The critical outcomes of interest were patient safety and personnel safety. The important outcomes of interest were personnel performance, acute fatigue, sleep and sleep quality, retention/turnover, long-term health, burnout/stress, and cost to system. Screeners worked independently and full-text articles were assessed for relevance. Data abstracted from the retained literature were categorized as favorable, unfavorable, mixed/inconclusive, or no impact toward the shorter shift duration. This research characterized the evidence as very low, low, moderate, or high quality according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

The searched yielded n = 21,674 records. Of the 480 full-text articles reviewed, 100 reported comparisons of outcomes of interest by shift duration. We identified 24 different shift duration comparisons, most commonly 8 hours versus 12 hours. No one study reported findings for all 9 outcomes. Two studies reported findings linked to both critical outcomes of patient and personnel safety, 34 reported findings for one of two critical outcomes, and 64 did not report findings for critical outcomes. Fifteen studies were grouped to compare shifts <24 hours versus shifts ≥24 hours. None of the findings for the critical outcomes of patient and personnel safety were categorized as unfavorable toward shorter duration shifts (<24 hours). Nine studies were favorable toward shifts <24 hours for at least one of the 7 important outcomes, while findings from one study were categorized as unfavorable. Evidence quality was low or very low.

CONCLUSIONS

The quality of existing evidence on the impact of shift duration on fatigue and fatigue-related risks is low or very low. Despite these limitations, this systematic review suggests that for outcomes considered critical or important to EMS personnel, shifts <24 hours in duration are more favorable than shifts ≥24 hours.

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.

A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms

PURPOSE

To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being.

METHOD

The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies.

RESULTS

A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs.

CONCLUSIONS

The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.

National Incidence of Medication Error in Surgical Patients Before and After Accreditation Council for Graduate Medical Education Duty-Hour Reform

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations.

DESIGN

Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals.

SETTING

We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions.

PARTICIPANTS

A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates).

RESULTS

The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted.

CONCLUSIONS

After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform.

Optimizing Quality of Care and Patient Safety in Malaysia: The Current Global Initiatives, Gaps and Suggested Solutions

BACKGROUND & OBJECTIVE

Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia.

DESIGN

Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed.

RESULTS

The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme "1 Care for 1 Malaysia" in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors.

CONCLUSIONS

There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia.

Scheduling in the context of resident duty hour reform

Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.

The subspecialization of surgery: a paradigm shift

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Inpatient safety outcomes following the 2011 residency work-hour reform

BACKGROUND

The impact of the 2011 residency work-hour reforms on patient safety is not known.

OBJECTIVE

To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center.

DESIGN

Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes.

PATIENTS

All adult patients discharged from general medicine services from July 2008 through June 2012.

MEASUREMENTS

Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index.

RESULTS

Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes.

CONCLUSIONS

In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.

Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units

BACKGROUND

Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a "shift" model, both with increased handoffs.

OBJECTIVE

To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments.

DESIGN

Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1-2 month periods.

SETTING

A mixed medical-surgical intensive care unit at a tertiary care academic center.

SUBJECTS

Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients.

INTERVENTIONS

Implementation of shift-work schedule, combined with structured sign-out curriculum.

MEASUREMENTS

Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance.

MAIN RESULTS

There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15).

CONCLUSIONS

A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

Outcomes of operations performed by attending surgeons after overnight trauma shifts

BACKGROUND

To date, work-hour restrictions have not been imposed on attending surgeons in the United States. The purpose of this study was to investigate the impact of working an overnight trauma shift on outcomes of general surgery operations performed the next day by the post-call attending physician.

STUDY DESIGN

Consecutive patients over a 3.5-year period undergoing elective general surgical procedures were reviewed. Procedures were limited to hernia repairs (inguinal and ventral), cholecystectomies, and intestinal operations. Any operations that were performed the day after the attending surgeon had taken an overnight trauma shift were considered post-call (PC) cases; all other cases were considered nonpost-call (NP). Outcomes from the PC operations were compared with those from the NP operations.

RESULTS

There were 869 patients identified; 132 operations were performed PC and 737 were NP. The majority of operations included hernia repairs (46%), followed by cholecystectomies (35%), and intestinal procedures (19%). Overall, the PC operations did not differ from the NP operations with respect to complication rate (13.7% vs 13.5%, p = 0.93) or readmission within 30 days (5% vs 6%, p = 0.84). Additionally, multivariable logistic regression failed to identify an association between PC operations and the development of adverse outcomes. Follow-up was obtained for an average of 3 months.

CONCLUSIONS

Performance of general surgery operations the day after an overnight in-hospital trauma shift did not affect complication rates or readmission rates. At this time, there is no compelling evidence to mandate work-hour restrictions for attending general surgeons.

Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers

Sleep deprivation is common among resident physicians and clinical fellows. Current evidence about sleep science, performance, shift work, and medical errors consistently demonstrates positive impact from reduction of excessive duty hours, particularly when shift length is shortened. This article provides an overview of this literature, highlighting research on diminished physician cognitive performance due to sleep deprivation and the increase in the number of medical errors that is seen under these conditions. Accreditation Council on Graduate Medical Education trainee duty hour guidelines are reviewed. Practical approaches to evidence-based scheduling of shift-work are also discussed, with attention to improving patient safety.

Factors associated with non-compliance during 16-hour long call shifts

BACKGROUND

Duty hour restrictions limit shift length to 16 hours during the 1(st) post-graduate year. Although many programs utilize a 16-hour "long call" admitting shift on inpatient services, compliance with the 16-hour shift length and factors responsible for extended shifts have not been well examined.

OBJECTIVE

To identify the incidence of and operational factors associated with extended long call shifts and residents' perceptions of the safety and educational value of the 16-hour long call shift in a large internal medicine residency program. DESIGN, PARTICIPANTS, AND MAIN MEASURES: Between August and December of 2010, residents were sent an electronic survey immediately following 16-hour long call shifts, assessing departure time and shift characteristics. We used logistic regression to identify independent predictors of extended shifts. In mid-December, all residents received a second survey to assess perceptions of the long call admitting model.

KEY RESULTS

Two-hundred and thirty surveys were completed (95 %). Overall, 92 of 230 (40 %) shifts included ≥ 1 team member exceeding the 16-hour limit. Factors independently associated with extended shifts per 3-member team were 3-4 patients (adjusted OR 5.2, 95 % CI 1.9-14.3) and>4 patients (OR 10.6, 95 % CI 3.3-34.6) admitted within 6 hours of scheduled departure and>6 total admissions (adjusted OR 2.9, 95 % CI 1.05-8.3). Seventy-nine of 96 (82 %) residents completed the perceptions survey. Residents believed, on average, teams could admit 4.5 patients after 5 pm and 7 patients during long call shifts to ensure compliance. Regarding the long call shift, 73 % agreed it allows for safe patient care, 60 % disagreed/were neutral about working too many hours, and 53 % rated the educational value in the top 33 % of a 9-point scale.

CONCLUSIONS

Compliance with the 16-hour long call shift is sensitive to total workload and workload timing factors. Knowledge of such factors should guide systems redesign aimed at achieving compliance while ensuring patient care and educational opportunities.

Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?

Long hours are an accepted component of resident education, yet data suggest they contribute to fatigue that may compromise patient safety. A systematic review confirms that limiting duty hours increases residents' hours of sleep and improves objective measures of alertness. Most studies of operative experience for surgical residents found no effect, and there is evidence of a limited positive effect on residents' mood. We find a mixed effect on patient safety, although problems with supervision, rather than the limits, may be responsible or contibute; evidence of reduced continuity of care and reduced continuity in residents' clinical education; and evidence that increased workload under the limits has a negative effect on patient and resident outcomes. We highlight specific areas for research and offer recommendations for national policy.

Less is more? The impact of trauma volume on the positive rate of head computed tomography scans in head trauma patients

Objective. Few studies have assessed the impact of trauma volume on the operational efficiency of emergency departments. Herein, we evaluate the association between trauma volume with the positive rate of head computed tomography scans in head trauma patients in a tertiary care hospital. Methods. This is a retrospective cohort review involving all head trauma patients presenting to a tertiary care hospital. Trauma census, head trauma patient volume, the number of emergent head CT scans, and the number of positive head CT scans were collected on a monthly basis. Comparison was primarily made between the trauma patient volume and the positive rate of head CT scans. Results. 25,549 trauma patients were reviewed. Of these, 5,168 (20.2%) sustained head trauma and 3,336 head CT scans were performed with mean 29.1% positive rate of substantial head injuries. The monthly data were analyzed and a statistically significant correlation between monthly trauma volume and decrease in positive rate of head CT scan was identified (Pearson r = −0.51, P = 0.02). With introducing different cut-point values of trauma volume, we identified the threshold of trauma census as approximately 4.9 and 8.8% higher than mean monthly trauma volume in discriminating significant decrease of positive rate of head CT scans.

Graduate medical education funding: a Massachusetts General Hospital case study and review

During the past century, graduate medical education funding has evolved in response to the increasing specialization of modern medicine as well as the need for federal funding to effectively sustain specialty training. This article reviews historical and current funding methods for graduate medical education and examines current funding using Massachusetts General Hospital (MGH) as a case example. Notably, it also explores whether graduate medical education funding at a large academic center such as MGH is commensurate with expenditures.

Patient safety, resident education and resident well-being following implementation of the 2003 ACGME duty hour rules

CONTEXT

The ACGME-released revisions to the 2003 duty hour standards.

OBJECTIVE

To review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.

DATA SOURCES

Medline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.

STUDY SELECTION

We included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.

DATA EXTRACTION

One rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.

RESULTS

Of 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.

LIMITATIONS

Most studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.

CONCLUSIONS

Since 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

Effect of 16-hour duty periods on patient care and resident education

OBJECTIVE

To measure the effect of duty periods no longer than 16 hours on patient care and resident education.

PATIENTS AND METHODS

As part of our Educational Innovations Project, we piloted a novel resident schedule for an inpatient service that eliminated shifts longer than 16 hours without increased staffing or decreased patient admissions on 2 gastroenterology services from August 29 to November 27, 2009. Patient care variables were obtained through medical record review. Resident well-being and educational variables were collected by weekly surveys, end of rotation evaluations, and an electronic card-swipe system.

RESULTS

Patient care metrics, including 30-day mortality, 30-day readmission rate, and length of stay, were unchanged for the 196 patient care episodes in the 5-week intervention month compared with the 274 episodes in the 8 weeks of control months. However, residents felt less prepared to manage cross-cover of patients (P = .006). There was a nonsignificant trend toward decreased perception of quality of education and balance of personal and professional life during the intervention month. Residents reported working fewer weekly hours overall during the intervention (64.3 vs 68.9 hours; P = .40), but they had significantly more episodes with fewer than 10 hours off between shifts (24 vs 2 episodes; P = .004).

CONCLUSION

Inpatient hospital services can be staffed with residents working shifts less than 16 hours without additional residents. However, cross-cover of care, quality of education, and time off between shifts may be adversely affected.

Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors

OBJECTIVE

To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.

METHODS

US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.

RESULTS

Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).

CONCLUSION

Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.

Early effects of resident work-hour restrictions on patient safety: a systematic review and plea for improved studies

BACKGROUND

since the inception of the eighty-hour work week, work hour restrictions have incited considerable debate. Work hour policies were designed to prevent medical errors and to reduce patient morbidity and mortality. It is unclear whether work hour restrictions have been helpful in medicine in general and in orthopaedic surgery specifically. This systematic review of the literature was designed to determine the success of these restrictions in terms of patient mortality, medical errors, and complications.

METHODS

a systematic review of the literature was performed to determine if work hour rules have improved patient and systems-based outcomes and reduced physician errors as measured by mortality, medical errors, and complications. A random effects model was utilized to determine whether patient mortality rates were improved under the new rules.

RESULTS

the odds of patient death before implementation of the work hour rules were 1.12 (95% confidence interval, 1.07 to 1.17) times those after implementation. These differences were consistent across disciplines. The data concerning medical or surgical complications before and after the institution of the work hour rules were mixed. There was little information in these studies concerning direct medical errors. The odds of death in nonteaching cohorts were not significantly different from that in teaching cohorts.

CONCLUSIONS

there appears to be a decrease in mortality following the institution of work hour rules. The difference seen in teaching cohorts is not significantly different from that in nonteaching cohorts. It is unclear whether this difference would have been observed even without work hour restrictions. No study has shown a reduction in mortality for orthopaedic patients in teaching cohorts that was greater than that observed in nonteaching cohorts. Because of methodological concerns and the lack of current literature linking physician fatigue and physician underperformance with patient mortality, it is unclear whether the goals of the work hour reductions have been achieved. Furthermore, because of a lack of a so-called dose-response relationship between work hour reduction and patient mortality, it is uncertain whether further reductions would be beneficial.

LEVEL OF EVIDENCE

therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review

STUDY OBJECTIVES

The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours.

DESIGN AND OUTCOME MEASURES

We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology.

MEASUREMENTS AND RESULTS

Twenty-three studies met inclusion criteria (kappa = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened.

CONCLUSIONS

In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.

The impact of fragmentation of hospitalist care on length of stay

BACKGROUND

Different hospitalist staffing models provide different levels of inpatient continuity of care, which may impact length of stay (LOS).

OBJECTIVE

To determine if fragmentation of care (FOC) by hospitalist physicians is associated with LOS.

DESIGN

Concurrent control study.

SETTING

Hospitalist practices managed by IPC The Hospitalist Company.

PATIENTS

A total of 10,977 patients admitted for diagnosis-related group (DRG) of 89 pneumonia with complications or comorbidities (PNA) or a DRG of 127 heart failure and shock (HF) between December 2006 and November 2007.

MEASUREMENTS

FOC was defined as the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay. Negative binomial regression was performed on DRG 89 and DRG 127 patients with LOS as the dependent variable. We adjusted for gender, age, severity of illness (SOI) scores, risk of mortality (ROM) scores, and number of secondary diagnoses, and admission day of the week.

RESULTS

A 10% increase in fragmentation was associated with an increase of 0.39 days (P < 0.0001) in the LOS for pneumonia, and an increase of 0.30 days (P < 0.0001) in LOS for heart failure.

CONCLUSIONS

As FOC increased for pneumonia and heart failure, the LOS increased significantly. Methods to reduce fragmentation should be explored, while more research is needed to identify the source of the relationship between FOC and LOS.

Cost implications of reduced work hours and workloads for resident physicians

BACKGROUND

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

METHODS

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

RESULTS

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

CONCLUSIONS

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

Four years of accreditation council of graduate medical education duty hour regulations: have they made a difference?

OBJECTIVES/HYPOTHESIS

Measure compliance with the Accreditation Council of Graduate Medical Education (ACGME) residents' work hour regulations and evaluate their impact on patient care and residents' performance on the Otolaryngology Training Examination (OTE).

STUDY DESIGN

Retrospective review of an otolaryngology residency program's resident duty hours violations and OTE scores, and review of the associated hospital's benchmark patient data.

METHODS

Residents' duty hour violations were compiled and analyzed for individual violation, postgraduate year (PGY), and service in the program. Annual OTE scores and the department's hospital benchmark measures (inpatient mortality, inpatient length of stay, 30-day readmission rate) were compared before and after the institution of the ACGME duty hours mandate.

RESULTS

The 10-hour rule was most frequently violated; residents on the oncology service and PGY-2 year were most commonly in violation. There was no difference before and after institution of the ACGME duty hours mandate in 30-day hospital readmission rates (P = .42), hospital mortality index (P = .55), length of stay (P = .55), OTE scores (P = .11, Student's t test), and graduating resident's operative volume.

CONCLUSIONS

Institution of the ACGME duty hour regulations did not improve patient care as measured by the 30-day readmission rate, inhospital mortality, and patient's length of stay. Residents' performance on the OTE did not change after implementation of the ACGME rules. Further studies are warranted to assess the impact of the ACGME work hour regulations on patient care and resident-physicians' training.

Hepato-pancreato-biliary training in general surgery residency: is it enough for the real world?

BACKGROUND

Advanced training in hepato-pancreato-biliary (HPB) surgery is available at select centers. No approved fellowships have yet been established.

OBJECTIVE

To determine the level of training in HPB surgery during general surgery residency and to assess the need for additional training.

METHOD

All general surgical residency programs in the United States were surveyed. Resident Review Committee (RRC) and International Hepato-Pancreato-Biliary Association (IHPBA) requirements were compared to Accreditation Council of Graduate Medical Education (ACGME) data.

RESULTS

Eighty of 250 general surgical residency programs (32%) responded to the survey. Eighty percent felt their graduating residents had sufficient HPB training. The average number of pancreatic cases per graduating resident was 10.2 +/- 7.3. The average number of hepatic resections was 8.6 +/- 5.1, and for complex biliary cases, 5.3 +/- 1.3.

CONCLUSIONS

A significant portion of HPB surgery is performed at transplant centers or by HPB surgeons. Guidelines must be established to assure adequate training. When HPB surgery is the main focus of the future practice, residents should seek additional training.