What do surgery residents do on their call nights?

Perceived Pager Burden Among Trainees Across Medical Specialties

BACKGROUND

The experiences of pager use among trainees across medical specialties is underexplored. The aim of this study was to assess experiences of pager burden and communication preferences among trainees in different specialties.

METHODS

An online survey was developed to assess perceived pager burden (eg, pager volume, mistake pages, sleep, and off-time interruptions) and communication preferences at a tertiary center in the United States. All residents and fellows were eligible to participate. Responses were grouped by specialty: General surgery [GS], Surgical subspecialty [SS], Medicine, Anesthesiology, and Psychiatry. Multivariable linear regression was used to assess factors associated with pager burden. Free text responses were analyzed using open coding methods.

RESULTS

Of the total 306 responses, the majority were female (58.8%), 30-39 years (59.2%), and White (70.6%). Specialty breakdown was: Medicine (40.2%), Psychiatry (10.8%), SS (18.0%), GS (5.6%), and Anesthesiology (3.6%). GS respondents reported receiving more mistake pages (P < .001), spending more time redirecting mistake pages (P = .003), and having the highest sleep time disruptions (P < .001). For urgent communications, surgical trainees preferred physical pagers, while nonsurgical trainees preferred smartphone pagers (P = .001). "Receive fewer nonurgent pages" was the most common change respondents desired.

DISCUSSION

In this single center study, subjective experiences of pager burden were disproportionately high among GS trainees. Reducing nonurgent and mistake pages are potential targets for improving trainee communication experiences. Hospitals should consider incorporating trainee preferences into paging systems. Additional studies are warranted to increase the sample size, assess generalizability of the findings, and contextualize trainee experiences with objective hospital-level paging data.

Ophthalmology on Call: Evaluating the Volume, Urgency, and Type of Pages Received at a Tertiary Care Center

Background: A significant proportion of on-call resident workload is related to answering and managing pages. Ophthalmology residents see high volumes of patients on call, but little is known about the profile of pages they receive. The objective of this study is to characterize the volume, type, and urgency of pages received by the ophthalmology on-call service.

Methods: A retrospective review of on-call pager log sheets and patient charts was performed at a single academic institution. Data were collected from July to December 2019, sampling the first seven days of each month. Data collected for each page included date/time of day, source, and primary concern. For each page leading to a patient encounter, time from page to patient assessment, patient demographics, and final diagnosis were recorded. Continuous variables were reported as mean values, whereas categorical variables were presented as percentages. A two-sample t-test and single-factor analysis of variance were employed.

Results: Over 42 days, 1108 pages were received. Over half of these calls required patient assessment, 71% of which were seen the same day. On average, 26 pages were received in 24 hours. Daytime weekday hours were significantly more busy than weekday nights or weekends (p<0.001). Patients and the emergency department each accounted for almost one-third of calls received. Retina- and cornea-related consults were most common.

Conclusions: Pager volumes in ophthalmology are high and on-call patient volumes are rising. Answering pages increases the on-call resident’s workload and has a negative impact on clinic flow. These data can be used to inform resident curriculum development, hospital system changes, patient education regarding appropriate paging, and medical school teaching.

An Analysis of the On-Call Clinical Experience of a Junior Neurosurgical Resident

The process of transforming a medical student to a competent neurosurgeon is becoming increasingly scrutinized and formalized. However, there are few data on resident workload.

We sought to quantify the workload and educational experience of a junior resident while “on-call.”

A single resident's on-call log was reviewed from the period of July 1, 2014 to June 30, 2016, corresponding to that resident's postgraduate years 2 and 3. For each patient encounter (ie, consult or admission), information pertaining to the patient's demographics, disease or reason for consult, date/time/location of consult, and need for any neurosurgical intervention within the first 24 hours was collected.

In total, 1929 patients were seen in consultation. The majority of patients were male (62%) with a median age of 50 years (range, day of life 0-102 years) and had traumatic diagnoses (52%). The number of consults received during the 16:00 to 17:00 and 17:00 to 18:00 hours was +1.6 and +2.5 standard deviations above the mean, respectively. The busiest and slowest months were May and January, respectively. Neurosurgical intervention performed within the first 24 hours of consultation occurred in 330 (17.1%) patients: 221 (11.4%) major operations, 69 (3.6%) external ventricular drains, and 40 (2.1%) intracranial pressure monitors.

This is the first study to quantify the workload and educational experience of a typical neurosurgical junior resident while “on-call” (ie, carrying the pager) for 2 consecutive years. It is our hope that these findings are considered by neurosurgical educators when refining resident education.

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study

Background

Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.

Objective

To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.

Methods

A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.

Results

In total, 250 participants were randomised (n = 125 CIRACT service,n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.

Conclusions

The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A Mobile, Collaborative, Real Time Task List for Inpatient Environments

BACKGROUND

Inpatient teams commonly track their tasks using paper checklists that are not shared between team members. Team members frequently communicate redundantly in order to prevent errors.

METHODS

We created a mobile, collaborative, real-time task list application on the iOS platform. The application listed tasks for each patient, allowed users to check them off as completed, and transmitted that information to all other team members. In this report, we qualitatively describe our experience designing and piloting the application with an inpatient pediatric ward team at an academic pediatric hospital.

RESULTS

We successfully created the tasklist application, however team members showed limited usage.

CONCLUSION

Physicians described that they preferred the immediacy and familiarity of paper, and did not experience an efficiency benefit when using the electronic tasklist.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.

Assessing the Value of Work Done by an Orthopedic Resident During Call

BACKGROUND

Medicare funding for graduate medical education may be cut in the next federal budget.

OBJECTIVE

We quantified the value of work that 1 orthopedic surgery resident performs on call and compare it to Medicare educational funding received by the hospital for each resident.

METHODS

A single orthopedic resident's on-call emergency department and inpatient consults were collected during a 2-year call period at a large, tertiary, level-1 trauma center. Patient charts were reviewed; ICD-9 codes, evaluation and management, and procedural treatment were recorded. Codes were converted into work relative value units. The number of work relative value units was multiplied by the 2012 Medicare rate of $34.03 per relative value units to calculate the monetary value of resident work.

RESULTS

Of 120 resident call shifts, 115 call sheets (95.8%) were available for review, and 1160 patients were seen (average  =  10.09 consults/call). A total of 4688 work relative value units were generated (average  =  40.76 per night), and the total dollar value generated was $159,561 ($1,387 per call) during the 2 years of call (average  =  $79,780 annually). Evaluation and management codes generated 2340 work relative value units, with a calculated dollar amount of $79,648, and procedural codes generated 2348 work relative value units, with a calculated dollar amount of $79,913.

CONCLUSIONS

Our institution estimated Medicare direct medical education support per resident at $40,000/y, and total funding was $130,000/resident. At our tertiary care institution, the unbilled work of 1 orthopedic resident on call amounts to more than 60% of Medicare direct medical education and indirect medical education funding annually.

Using NNAPPS (Nighttime Nurse and Physician Paging System) to Maximize Resident Call Efficiency within 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions

OBJECTIVES

To assess if implementing Nighttime Nurse and Physician Paging System (NNAPPS) would improve nurse and physician communication as well as reduce the number of nonurgent pages to residents taking overnight call.

DESIGN

NNAPPS was implemented on the busiest General Surgery and Transplant wards at our University Hospital. We conducted 2 prospective studies that logged pages received by on call surgery residents for 2-month blocks. The logs captured time, source, reason, and action resulting from pages. Independent reviewers determined urgency of the pages. Primary outcome measures were comparison of average nonurgent pages, total pages and total pages per patient during a night shift between the NNAPPS ward and all other wards that care for surgical patients.

SETTING

University teaching hospital.

PARTICIPANTS

General surgery residents working overnight call shifts on nine surgical services.

RESULTS

In both studies combined, there were a total of 107 night shifts during which 771 pages were received. Total census was 1179 patients. Nurses initiated most pages (67%). Eight percent of pages interrupted patient care, while 40% of pages interrupted resident sleep. Most pages resulted in either a "new order" (39%) or "patient assessment" (22%), while 36% resulted in "no action." Most pages (56%) were "urgent," 25% "nonurgent," and 19% "unable to determine urgency." Regarding the Transplant ward, significant differences (p < 0.05) existed between average nonurgent pages (0.46 vs 2.14), total pages (3.69 vs 6.14) and total pages/patient during a shift (0.38 vs 0.68) when comparing pre- and post-NNAPPS data.

CONCLUSIONS

NNAPPS significantly reduced nonurgent pages, total pages and pages per patient during a night shift compared to services with conventional systems. Streamlined paging systems lead to more efficient communication between providers and decrease the nonurgent pages to residents. NNAPPS continued high standards of patient care and improved sleep patterns for residents.

On-call emergency workload of a general surgical team

Background:

To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services.

Patients and Methods:

During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E) and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography.

Results:

Total 456 patients (326 males and 130 females) were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9%) were received from 8 am to 5 pm. 224 (49.1%) calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0%) patients. Total 73 (16.0%) calls were received for trauma. Total 131 (28.7%) patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5%) patients were discharged from A and E. 92 (20.1%) patients were referred to other units with medical referral accounts for 45 (9.8%) patients. Total 104 (22.8%) emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7%) patients.

Conclusion:

Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.

Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians

BACKGROUND

Hospital physicians' time is a critical resource in medical care. Two aspects are of interest. First, the time spent in direct patient contact - a key principle of effective medical care. Second, simultaneous task performance ('multitasking') which may contribute to medical error, impaired safety behaviour, and stress. There is a call for instruments to assess these aspects. A preliminary study to gain insight into activity patterns, time allocation and simultaneous activities of hospital physicians was carried out. Therefore an observation instrument for time-motion-studies in hospital settings was developed and tested.

METHODS

35 participant observations of internists and surgeons of a German municipal 300-bed hospital were conducted. Complete day shifts of hospital physicians on wards, emergency ward, intensive care unit, and operating room were continuously observed. Assessed variables of interest were time allocation, share of direct patient contact, and simultaneous activities. Inter-rater agreement of Kappa = .71 points to good reliability of the instrument.

RESULTS

Hospital physicians spent 25.5% of their time at work in direct contact with patients. Most time was allocated to documentation and conversation with colleagues and nursing staff. Physicians performed parallel simultaneous activities for 17-20% of their work time. Communication with patients, documentation, and conversation with colleagues and nursing staff were the most frequently observed simultaneous activities. Applying logit-linear analyses, specific primary activities increase the probability of particular simultaneous activities.

CONCLUSION

Patient-related working time in hospitals is limited. The potential detrimental effects of frequently observed simultaneous activities on performance outcomes need further consideration.

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.