Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients

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.

Pulling Back from the Brink: A Multi-Pronged Approach to Address General Surgery Resident Clinical Work Hour Adherence

PURPOSE

The conflict between prioritizing education for surgical trainees, promoting trainee wellness, and maintaining optimal patient care has remained challenging since the introduction of the Accreditation Council for Graduate Medical Education (ACGME) work hour restrictions in 2003. There is still a dearth of research examining which interventions successfully enable duty hour adherence. This study assessed the impact of a combination of strategic interventions on improving clinical work hour adherence.

METHODS

Monthly clinical work hour submission rates were assessed for all general surgery residents at a single university-based residency program over a 3-year period (2018-2021). Interventions targeted 3 domains and were implemented between academic years 2018 to 2019 (control) and 2020 to 2021 (intervention): 1) improving the accuracy and transparency of work hour reporting, 2) facilitating more timely interventions, and 3) structural scheduling changes. All 80-hour work week and continuous work hour violations were assessed. Findings were also compared to the corresponding ACGME Resident Survey results.

RESULTS

There was no significant difference in the rate of monthly work hour submissions pre- and postintervention (78% vs 75%, p = 0.057). However, the number of total reported monthly violations decreased significantly (mean 13.8 vs 2.4, p < 0.01), including decreases in both 80-hour work week and continuous work hour violations (mean 4.7 vs 1.6, p < 0.001 and 9.1 vs 0.8, p < 0.001, respectively). Reported compliance also increased on the annual ACGME resident surveys, where 61% vs 95% of residents felt they were compliant with the 80-hour work week and 71% vs 95% felt they were compliant with the continuous work hours (2018-19 vs 2020-21).

CONCLUSION

Innovative strategies addressing schedule changes, the culture of work hour reporting, and early intervention significantly decreased the number of duty hour violations at our institution. Reported resident compliance also improved based on ACGME Resident Survey data. These data may inform similar multifaceted approaches at other institutions to improve overall work hour adherence.

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons

OBJECTIVE

The aim of the study was to address the controversy surrounding the effects of duty hour reform on new surgeon performance, we analyzed patients treated by new surgeons following the transition to independent practice.

SUMMARY BACKGROUND DATA

In 2003, duty hour reform affected all US surgical training programs. Its impact on the performance of new surgeons remains unstudied.

METHODS

We studied 30-day mortality among 1,483,074 Medicare beneficiaries undergoing general and orthopedic operations between 1999 and 2003 ("traditional" era) and 2009 and 2013 ("modern" era). The operations were performed by 2762 new surgeons trained before the reform, 2119 new surgeons trained following reform and 15,041 experienced surgeons. We used a difference-in-differences analysis comparing outcomes in matched patients treated by new versus experienced surgeons within each era, controlling for the hospital, operation, and patient risk factors.

RESULTS

Traditional era odds of 30-day mortality among matched patients treated by new versus experienced surgeons were significantly elevated [odds ratio (OR) 1.13; 95% confidence interval (CI) (1.05, 1.22), P < 0.001). The modern era elevated odds of mortality were not significant [OR 1.06; 95% CI (0.97-1.16), P = 0.239]. Relative performance of new and experienced surgeons with respect to 30-day mortality did not appear to change from the traditional era to the modern era [OR 0.93; 95% CI (0.83-1.05), P = 0.233]. There were statistically significant adverse changes over time in relative performance to experienced surgeons in prolonged length of stay [OR 1.08; 95% CI (1.02-1.15), P = 0.015], anesthesia time [9 min; 95% CI (8-10), P < 0.001], and costs [255USD; 95% CI (2-508), P = 0.049].

CONCLUSIONS

Duty hour reform showed no significant effect on 30-day mortality achieved by new surgeons compared to their more experienced colleagues. Patients of new surgeons, however, trained after duty hour reform displayed some increases in the resources needed for their care.

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.

Key Components of the Safe Surgical Ward: International Delphi Consensus Study to Identify Factors for Quality Assessment and Service Improvement

OBJECTIVE

The aim of this study was to prioritize key factors contributing to safety on the surgical ward BACKGROUND:: There is a variation in the quality and safety of postoperative care between institutions. These variations may be attributed to a combination of process-related issues and structural factors. The aim of this study is to reach a consensus, by means of Delphi methodology, on the most influential of these components that may determine safety in this environment.

METHODS

The Delphi questionnaire was delivered via an online questionnaire platform. The panel were blinded. An international panel of safety experts, both clinical and nonclinical, and safety advocates participated. Individuals were selected according to their expertise and extent of involvement in patient safety research, regulation, or patient advocacy.

RESULTS

Experts in patient safety from the UK, Europe, North America, and Australia participated. The panel identified the response to a deteriorating patient and the care of outlier patients as error-prone processes. Prioritized structural factors included organizational and environmental considerations such as use of temporary staff, out-of-hours reduction in services, ward cleanliness, and features of layout. The latter includes dedicated areas for medication preparation and adequate space around the patient for care delivery. Potential quality markers for safe care that achieved the highest consensus include leadership, visibility between patients and nurses, and nursing team skill mix and staffing levels.

CONCLUSION

International consensus was achieved for a number of factors across process-related and structural themes that may influence safety in the postoperative environment. These should be championed and prioritized for future improvements in patient safety at the ward-level.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

BACKGROUND

Concern persists that extended shifts in medical residency programs may adversely affect patient safety.

METHODS

We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.

RESULTS

The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.

CONCLUSIONS

Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine

INTRODUCTION

Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness.

METHODS AND ANALYSIS

63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses.

ETHICS AND DISSEMINATION

The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process.

TRIAL REGISTRATION NUMBER

NCT02274818; Pre-results.

Reduced Resident Work Hours in Urology: The History and Impact of Duty Hour Restrictions

INTRODUCTION

The ACGME first mandated duty hour restrictions for resident physicians in 2003, setting a limit of 80 hours per week. While the goals of this and later reforms were to improve patient care and safety, the outcomes have been mixed. In this review we report on the history of duty hour regulations and how these changes have impacted resident and patient outcomes.

METHODS

A literature search was performed, and articles discussing surgical training, resident duty hours, resident wellness and patient outcomes were reviewed.

RESULTS

After implementation of duty hour restrictions in 2003, the Harvard Work Hours Health and Safety Group published 3 hallmark studies that suggested duty hour restrictions were associated with improved outcomes. A recently published systematic review reported mixed results from the growing body of research. While 71% of the reviewed studies reported improvement in resident wellness, only 4% illustrated an improvement in resident education, 19% reported improved patient safety outcomes and 13% demonstrated improved patient morbidity.

CONCLUSIONS

Resident duty hour restrictions were based on a body of evidence illustrating that fatigue and sleeplessness negatively impact decision making, resident wellness and patient care. While initial outcomes suggested that these regulations resulted in better resident and patient outcomes, more recent evidence suggests otherwise. There is very little urology specific evidence addressing these matters.

National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training

BACKGROUND

Concerns persist regarding the effect of current surgical resident duty-hour policies on patient outcomes, resident education, and resident well-being.

METHODS

We conducted a national, cluster-randomized, pragmatic, noninferiority trial involving 117 general surgery residency programs in the United States (2014-2015 academic year). Programs were randomly assigned to current Accreditation Council for Graduate Medical Education (ACGME) duty-hour policies (standard-policy group) or more flexible policies that waived rules on maximum shift lengths and time off between shifts (flexible-policy group). Outcomes included the 30-day rate of postoperative death or serious complications (primary outcome), other postoperative complications, and resident perceptions and satisfaction regarding their well-being, education, and patient care.

RESULTS

In an analysis of data from 138,691 patients, flexible, less-restrictive duty-hour policies were not associated with an increased rate of death or serious complications (9.1% in the flexible-policy group and 9.0% in the standard-policy group, P=0.92; unadjusted odds ratio for the flexible-policy group, 0.96; 92% confidence interval, 0.87 to 1.06; P=0.44; noninferiority criteria satisfied) or of any secondary postoperative outcomes studied. Among 4330 residents, those in programs assigned to flexible policies did not report significantly greater dissatisfaction with overall education quality (11.0% in the flexible-policy group and 10.7% in the standard-policy group, P=0.86) or well-being (14.9% and 12.0%, respectively; P=0.10). Residents under flexible policies were less likely than those under standard policies to perceive negative effects of duty-hour policies on multiple aspects of patient safety, continuity of care, professionalism, and resident education but were more likely to perceive negative effects on personal activities. There were no significant differences between study groups in resident-reported perception of the effect of fatigue on personal or patient safety. Residents in the flexible-policy group were less likely than those in the standard-policy group to report leaving during an operation (7.0% vs. 13.2%, P<0.001) or handing off active patient issues (32.0% vs. 46.3%, P<0.001).

CONCLUSIONS

As compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality. (FIRST ClinicalTrials.gov number, NCT02050789.).

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.

The Elusive Goal of Accountability in Graduate Medical Education

Repeated calls for greater accountability of graduate medical education (GME) have been issued in recent years. In this context, Kenneth Ludmerer's Let Me Heal examines the issue of duty hours limits and paints a picture of failed accountability. The ways in which duty hours regulations have failed are discussed, pointing toward a need to focus on goals and outcomes (such as patient safety) rather than process (such as schedules and shift length).This Commentary considers key issues-who should be accountable, for what, and to whom?-and proposes a potential path for achieving accountability in GME. The author draws from consensus reports published by the Josiah Macy Jr. Foundation and the Institute of Medicine to outline the case for why the U.S. system of GME should be accountable to the public, to individual patients, and to the residents and fellows being educated. Domains of accountability include graduating competent physicians, producing the right workforce, and ensuring an efficient and cost-effective training process that is designed to protect patients. In addition, the author argues that GME should be accountable for providing trainees with reasonable working conditions and compensation.Key requirements for achieving meaningful GME accountability are proposed, including (1) a more effective partnership with the public; (2) explicit goals and assigned responsibilities, reflecting reasonable expectations of what GME can accomplish; (3) reliable metrics for GME outcomes; and (4) a governance system that provides coordination and has the authority to effect changes.

How to Further Decrease the Efficiency of Care at a Level I Trauma Center: Implement the Amended Resident Work Hours

Work-hour restrictions were amended in 2011 to limit interns to 16 continuous duty hours, essentially requiring a night float system of 12-hour shifts. We hypothesize that there has been no improvement in outcomes after implementation of the amended work-hour restrictions. Outcomes from trauma admissions were queried from the trauma registry from 2009 to 2011 (PRE) and 2011 to 2013 (POST). The primary outcome was mortality with secondary outcomes intensive care unit length of stay (LOS) and LOS. Patients were stratified based on age, mechanism, gender, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Scale, Base Deficit). Outcomes were then compared from admissions PRE to POST. A total of 9178 patients were included in the study population. The mean age was 42 with most being male (72%) and blunt mechanism (81%). Patient populations were well matched except patients in the POST period were slightly older (43 vs 42 years; P = 0.01). Intensive care unit LOS and LOS were higher in the POST period. After adjusted analysis, admission in the POST period was not a predictor of mortality (odds ratio 0.857; confidence interval 0.655–1.12). The POST period was an independent predictor for LOS (β = 0.74; P = 0.002). This study adds to the mounting evidence that the implementation of the amended limits on work hours leads to furthermore decreased efficiency of care.

Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores the relationships between residents' error rates and three clinical training methods (1) progressive independence or level of autonomy, (2) consulting the physician on call, and (3) familiarity with up-to-date medical literature, and whether these relationships vary among the specialties of surgery and internal medicine and between novice and experienced residents. 142 Residents in 22 medical departments from two hospitals participated in the study. Results of hierarchical linear model analysis indicated that lower levels of autonomy, higher levels of consultation with the physician on call, and higher levels of familiarity with up-to-date medical literature were associated with lower levels of resident's error rates. The associations varied between internal and surgery specializations and novice and experienced residents. In conclusion, the study results suggested that the implicit curriculum that residents should be afforded autonomy and progressive independence with nominal supervision in accordance with their relevant skills and experience must be applied cautiously depending on specialization and experience. In addition, it is necessary to create a supportive and judgment free climate within the department that may reduce a resident's hesitation to consult the attending physician.

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients

IMPORTANCE

Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.

OBJECTIVE

To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of Medicare patient admissions (6,384,273 admissions from 2,790,356 patients) to short-term, acute care, nonfederal hospitals (n = 3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching.

EXPOSURE

Resident-to-bed ratio as a continuous measure of hospital teaching intensity.

MAIN OUTCOMES AND MEASURES

Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009-June 30, 2011) and after (July 1, 2011-June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site.

RESULTS

In the 2 years before duty hour reforms, there were 4,325,854 admissions with 288,422 deaths and 602,380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2,058,419 admissions with 133,547 deaths and 272,938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category.

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

Different views about work-hour limitations in medicine: a qualitative content analysis of surgeons', lawyers', and pilots' positive and negative arguments

Background

Whereas work-hour regulations have been taken for granted since 1940 in other occupational settings, such as commercial aviation, they have been implemented only recently in medical professions, where they lead to a lively debate. The aim of the present study was to evaluate arguments in favour of and against work-hour limitations in medicine given by Swiss surgeons, lawyers, and pilots.

Methods

An electronic questionnaire survey with four free-response items addressing the question of what arguments speak in favour of or against work-hour limitations in general and in medicine was sent to a random sample of board-certified surgeons, lawyers in labour law, and pilots from SWISS International Airlines Ltd.

Results

In all, 279/497 (56%) of the respondents answered the survey: 67/117 surgeons, 92/226 lawyers, and 120/154 pilots. Support for work-hour limitations in general and in medicine was present and higher among lawyers and pilots than it was in surgeons (p<0.001). The latter agreed more with work-hour limitations in general than in medicine (p<0.001). The most often cited arguments in favour of work-hour limitations were “quality and patient safety,” “health and fitness,” and “leisure and work-family balance,” whereas the lack of “flexibility” was the most important argument against. Surgeons expected more often that their “education” and the “quality of their work” would be threatened (p<0.001).

Conclusions

Work-hour limitations should be supported in medicine also, but a way must be found to reduce problems resulting from discontinuity in patient care and to minimise the work in medicine, which has no education value.

Patient safety in the era of the 80-hour workweek

OBJECTIVE

In 2003, duty-hour regulations (DHR) were initially implemented for residents in the United States to improve patient safety and protect resident's well-being. The effect of DHR on patient safety remains unclear. The study objective was to evaluate the effect of DHR on patient safety.

DESIGN

Using an interrupted time series analysis, we analyzed selected patient safety indicators (PSIs) for 376 million discharges in teaching (T) vs nonteaching (NT) hospitals before and after implementation of DHR in 2003 that restricted resident work hours to 80 hours per week. The PSIs evaluated were postoperative pulmonary embolus or deep venous thrombosis (PEDVT), iatrogenic pneumothorax (PTx), accidental puncture or laceration, postoperative wound dehiscence (WD), postoperative hemorrhage or hematoma, and postoperative physiologic or metabolic derangement. Propensity scores were used to adjust for differences in patient comorbidities between T and NT hospitals and between discharge quarters. The primary outcomes were differences in the PSI rates before and after DHR implementation. The PSI differences between T and NT institutions were the secondary outcome.

SETTING

T and NT hospitals in the United States.

PARTICIPANTS

Participants were 376 million patient discharges from 1998 to 2007 in the Nationwide Inpatient Sample.

RESULTS

Declining rates of PTx in both T and NT hospitals preintervention slowed only in T hospitals postintervention (p = 0.04). Increasing PEDVT rates in both T and NT hospitals increased further only in NT hospitals (p = 0.01). There were no differences in the PSI rates over time for hemorrhage or hematoma, physiologic or metabolic derangement, accidental puncture or laceration, or WD. T hospitals had higher rates than NT hospitals both preintervention and postintervention for all the PSIs except WD.

CONCLUSIONS

Trends in rates for 2 of the 6 PSIs changed significantly after DHR implementation, with PTx rates worsening in T hospitals and PEDVT rates worsening in NT hospitals. Lack of consistent patterns of change suggests no measurable effect of the policy change on these PSIs.

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.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery.

METHODS

A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality.

RESULTS

A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented.

CONCLUSIONS

Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery

OBJECTIVE

To perform a systematic review of interventions used to reduce adverse events in surgery.

BACKGROUND

Many interventions, which aim to improve patient safety in surgery, have been introduced to hospitals. Little is known about which methods provide a measurable decrease in morbidity and mortality.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched from inception to Week 19, 2012, for systematic reviews, randomized controlled trials (RCTs), and cross-sectional and cohort studies, which reported an intervention aimed toward reducing the incidence of adverse events in surgical patients. The quality of observational studies was measured using the Newcastle-Ottawa Scale. RCTs were assessed using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

Ninety-one studies met inclusion criteria, 26 relating to structural interventions, 66 described modifying process factors. Only 17 (of 42 medium to high quality studies) reported an intervention that produced a significant decrease in morbidity and mortality. Structural interventions were: improving nurse to patient ratios (P = 0.008) and Intensive Care Unit (ITU) physician involvement in postoperative care (P < 0.05). Subspecialization in surgery reduced technical complications (P < 0.01). Effective process interventions were submission of outcome data to national audit (P < 0.05), use of safety checklists (P < 0.05), and adherence to a care pathway (P < 0.05). Certain safety technology significantly reduced harm (P = 0.02), and team training had a positive effect on patient outcome (P = 0.001).

CONCLUSIONS

Only a small cohort of medium- to high-quality interventions effectively reduce surgical harm and are feasible to implement. It is important that future research remains focused on demonstrating a measurable reduction in adverse events from patient safety initiatives.

Assessing the effects of the 2003 resident duty hours reform on internal medicine board scores

PURPOSE

To determine whether the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hours reform affected medical knowledge as reflected by written board scores for internal medicine (IM) residents.

METHOD

The authors conducted a retrospective cohort analysis of postgraduate year 1 (PGY-1) Internal Medicine residents who started training before and after the 2003 duty hour reform using a merged data set of American Board of Internal Medicine (ABIM) Board examination and the National Board of Medical Examiners (NMBE) United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge test scores. Specifically, using four regression models, the authors compared IM residents beginning PGY-1 training in 2000 and completing training unexposed to the 2003 duty hours reform (PGY-1 2000 cohort, n = 5,475) to PGY-1 cohorts starting in 2001 through 2005 (n = 28,008), all with some exposure to the reform.

RESULTS

The mean ABIM board score for the unexposed PGY-1 2000 cohort (n = 5,475) was 491, SD = 85. Adjusting for demographics, program, and USMLE Step 2 exam score, the mean differences (95% CI) in ABIM board scores between the PGY-1 2001, 2002, 2003, 2004 and 2005 cohorts minus the PGY-1 2000 cohort were -5.43 (-7.63, -3.23), -3.44 (-5.65, -1.24), 2.58 (0.36, 4.79), 11.10 (8.88, 13.33) and 11.28 (8.98, 13.58) points respectively. None of these differences exceeded one-fifth of an SD in ABIM board scores.

CONCLUSIONS

The duty hours reforms of 2003 did not meaningfully affect medical knowledge as measured by scores on the ABIM board examinations.

Teaching and Assessing Colorectal Surgery Residents in the Age of ACGME Competencies: Pieces of the Whole

Educators have struggled with teaching and evaluation of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies since their introduction in 1999. In addition, many authors have questioned the construct validity of the competencies. Concern has also arisen regarding the educational effects of the competencies and the subsequent limitation of resident duty hours, the combination of which have forced unprecedented changes in American graduate medical education. This article attempts to present an understanding of how these events have had direct and indirect effects on the education of residents in colon and rectal surgery, and to provide a framework for educators in colon and rectal surgery to adapt in their curricula.

Follow-up on a national survey: american neurosurgery resident opinions on the 2011 accreditation council for graduate medical education-implemented duty hours

OBJECTIVE

We previously performed a nationwide survey of American neurosurgical residents before the initiation of the 2011 Accreditation Council for Graduate Medical Education regulations, in which more than 70% indicated the proposed changes would negatively impact residency training. We sought to resurvey the resident population as to the actual changes that occurred to their programs after the 2011 standards went into effect.

METHODS

Surveys were mailed to every neurosurgery training program in the United States and Puerto Rico. Program directors and coordinators were asked to distribute surveys to their residents.

RESULTS

A total of 253 neurosurgery residents responded. Reported duty-hour violations were largely unchanged after the 2011 duty-hour changes. Sixty-percent of residents reported that they had underreported duty hours, with nearly 25% of respondents doing so on a weekly or daily basis. Most reported that the 2011 changes had not affected operative caseload, academic productivity, quality of life, or resident fatigue. The majority of residents disagreed or strongly disagreed that the PGY-1 16-hour limitation had a positive impact on first-year resident training (69%) or had improved patient safety (62%). Overall, the majority of respondents reported that the 2011 changes had a negative (35%) or negligible (33%) effect on residency training at their institution.

CONCLUSION

Respondents indicated that the 2011 Accreditation Council for Graduate Medical Education regulations have had a smaller perceived effect on neurosurgical training programs than previously predicted. However, the majority of residents admitted to underreporting duty hours, with a quarter doing so on a regular basis. The 16-hour rule for interns remains unpopular.

Teaching hospital five-year mortality trends in the wake of duty hour reforms

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined.

OBJECTIVE

To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform.

DESIGN

Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site.

PATIENTS

Medicare patients (n = 13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery.

MAIN MEASURE

All-location mortality within 30 days of hospital admission.

KEY RESULTS

In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1-3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93-0.94]); Post5 (OR 0.87, [0.82-0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85-0.96]).

CONCLUSIONS

Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded.

Does admission to a teaching hospital affect acute myocardial infarction survival?

PURPOSE

Previous studies have found that teaching hospitals produce better acute myocardial infarction (AMI) outcomes than nonteaching hospitals. However, these analyses generally excluded patients transferred out of nonteaching hospitals and did not study outcomes by patient risk level. The objective of this study was to determine whether admission to a teaching hospital was associated with greater survival after accounting for patient transfers and patient severity.

METHOD

This observational study used logistic models to examine the association between hospital teaching status and 30-day mortality of AMI patients, adjusting for patient comorbidities and common time trends. The sample included 1,309,554 Medicare patients admitted from 1996 to 2004 to 3,761 acute care hospitals for AMI. The primary outcome was 30-day all-cause, all-location mortality.

RESULTS

Mortality was slightly lower in minor teaching hospitals compared with nonteaching hospitals (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.95-0.99) but not different between major teaching and nonteaching hospitals (OR 1.01; 95% CI 0.96-1.03). The odds of mortality in minor teaching hospitals decreased 4.2% relative to nonteaching hospitals during the seven-year period (OR from 0.98 to 0.94). There was no consistent pattern of association between teaching status and patient severity.

CONCLUSIONS

After correctly accounting for the ability of nonteaching hospitals to appropriately transfer patients in need of different care, there was no survival benefit on average for initial admission to a teaching hospital for AMI. Further more, higher-risk patients did not benefit from initial admission to teaching hospitals.

Teaching hospital financial status and patient outcomes following ACGME duty hour reform

OBJECTIVE

To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.

DATA SOURCES/STUDY SETTING

Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.

STUDY DESIGN

Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).

PRINCIPAL FINDINGS

All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).

CONCLUSIONS

The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.

Recent family medicine residency graduates' perceptions of resident duty hour restrictions

BACKGROUND

Resident duty hour limits, new requirements for supervision, and an enhanced focus on patient safety have shown mixed effects on resident quality of life, patient safety, and resident competency. Few studies have assessed how recent graduates feel these changes have affected their education.

OBJECTIVE

We assessed recent graduates' perceptions about the effects of duty hour and supervision requirements on their education.

METHODS

We conducted a cross-sectional survey of graduates from South Carolina Area Health Education Consortium-affiliated family medicine residency programs from 2005 to 2009 by using logistic regression to determine associations between participant characteristics and survey responses.

RESULTS

Graduates (N  =  136) completed the survey with a 51.3% response rate. Nearly all (96%) reported that residency prepared them for their current work hours; 97% reported they felt adequately supervised; 81% worked fewer hours in practice than in residency; 20% believed the limits had restricted their clinical experience; and 3% felt duty hour limits were more important than supervision. Graduates who practiced in a mid-sized communities were more likely to report duty hour limits restricted their clinical experience than individuals practicing in communities of <10 000 (OR  =  6.30; 95% CI, 1.38-28.72).

CONCLUSIONS

Most graduates who responded to the survey felt supervision was equally or more important than limits on resident duty hours. However, 20% of respondents felt that the duty hour standards limited their education. The duty hour and supervision requirements challenge educators to ensure quality education.

Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight

RATIONALE AND OBJECTIVES

To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.

MATERIALS AND METHODS

Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.

RESULTS

We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy.

CONCLUSIONS

In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

A narrative review of surgical resident duty hour limits: where do we go from here?

BACKGROUND

Resident duty hour limits have been a point of debate among educators, administrators, and policymakers alike since the Libby Zion case in 1984. Advocates for duty hour limits in the surgical subspecialties cite improvements in patient safety, whereas opponents claim that limiting resident duty hours jeopardizes resident education and preparedness for independent surgical practice.

METHODS

Using orthopaedic surgery as an example, we describe the historical context of the implementation of the duty hour standards, provide a review of the literature presenting data that both supports and refutes continued restrictions, and outline suggestions for policy going forward that prioritize patient safety while maintaining an enhanced environment for resident education.

RESULTS

Although patient safety markers have improved in some studies since the implementation of duty hour limits, it is unclear whether this is due to changes in residency training or external factors. The literature is mixed regarding academic performance and trainee readiness during and after residency.

CONCLUSION

Although excessive duty hours and resident fatigue may have historically contributed to errors in the delivery of patient care, those are certainly not the only concerns. An overall "culture of safety," which includes pinpointing systematic improvements, identifying potential sources of error, raising performance standards and safety expectations, and implementing multiple layers of protection against medical errors, can continue to augment safety barriers and improve patient care. This can be achieved within a more flexible educational environment that protects resident education and ensures optimal training for the next generation of physicians and surgeons.

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions

BACKGROUND

By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care.

OBJECTIVE

Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission.

METHODS

We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003-2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting "Technical Care," "Continuity of Care," and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s).

RESULTS

The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19-1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03-1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27-2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08-1.22) to 37% higher for the Continuity of Care composite (CI, 1.26-1.50).

CONCLUSIONS

Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial

CONTEXT

A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements.

OBJECTIVE

To evaluate the feasibility and consequences of protected sleep periods during extended duty.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010). Of the 106 interns and senior medical students who consented, 3 were not scheduled on any study rotations. Among the others, 44 worked at the VA center, 16 at the university hospital, and 43 at both.

INTERVENTION

Twelve 4-week blocks were randomly assigned to either a standard intern schedule (extended duty overnight shifts of up to 30 hours; equivalent to 1200 overnight intern shifts at each site), or a protected sleep period (protected time from 12:30 AM to 5:30 AM with handover of work cell phone; equivalent to 1200 overnight intern shifts at each site). Participants were asked to wear wrist actigraphs and complete sleep diaries.

MAIN OUTCOME MEASURES

Primary outcome was hours slept during the protected period on extended duty overnight shifts. Secondary outcome measures included hours slept during a 24-hour period (noon to noon) by day of call cycle and Karolinska sleepiness scale.

RESULTS

For 98.3% of on-call nights, cell phones were signed out as designed. At the VA center, participants with protected sleep had a mean 2.86 hours (95% CI, 2.57-3.10 hours) of sleep vs 1.98 hours (95% CI, 1.68-2.28 hours) among those who did not have protected hours of sleep (P < .001). At the university hospital, participants with protected sleep had a mean 3.04 hours (95% CI, 2.77-3.45 hours) of sleep vs 2.04 hours (95% CI, 1.79-2.24) among those who did not have protected sleep (P < .001). Participants with protected sleep were significantly less likely to have call nights with no sleep: 5.8% (95% CI, 3.0%-8.5%) vs 18.6% (95% CI, 13.9%-23.2%) at the VA center (P < .001) and 5.9% (95% CI, 3.1%-8.7%) vs 14.2% (95% CI, 9.9%-18.4%) at the university hospital (P = .001). Participants felt less sleepy after on-call nights in the intervention group, with Karolinska sleepiness scale scores of 6.65 (95% CI, 6.35-6.97) vs 7.10 (95% CI, 6.85-7.33; P = .01) at the VA center and 5.91 (95% CI, 5.64-6.16) vs 6.79 (95% CI, 6.57-7.04; P < .001) at the university hospital.

CONCLUSIONS

For internal medicine services at 2 hospitals, implementation of a protected sleep period while on call resulted in an increase in overnight sleep duration and improved alertness the next morning.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00874510.

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.

Examining the relationship between processes of care and selected AHRQ patient safety indicators postoperative wound dehiscence and accidental puncture or laceration using the VA electronic medical record

This study examines whether Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) Postoperative Wound Dehiscence (PWD) and Accidental Puncture or Laceration (APL) events reflect problems with hospital processes of care (POC). The authors randomly selected 112 PSI-flagged PWD/APL discharges from 2002-2007 VA administrative data, identified true cases using chart review, and matched cases with controls. This yielded a total of 95 case-control pairs per PSI. Patient information and clinical processes on each case-control pair were abstracted from the electronic medical record (EMR). Although PWD cases and controls differed on incision and closure types, APL cases and controls were comparable in examined processes. Further exploration of the process differences between PWD cases and controls indicated that they were primarily caused by patients' underlying surgical problems rather than quality of care shortfalls. Documentation of POC was frequently missing in EMRs. Future studies should combine EMR review with alternative approaches, such as direct observation, to better assess POC.

Handoff Communication: Implications For Design

Handoff communication is one of the most typical clinical communication mechanisms in a healthcare setting to transfer information and responsibilities of the care provider. Handoff communication is varied across settings, provider type, and even within a clinical unit. Information technology has the capability to support handoff communication, with better understanding of handoff communication needs and variations. This panel examines (1) how handoff communication happens in the healthcare setting through mini-cases (2) insights on information technology design for handoff communication.

Anticipated consequences of the 2011 duty hours standards: views of internal medicine and surgery program directors

PURPOSE

To assess internal medicine (IM) and surgery program directors' views of the likely effects of the 2011 Accreditation Council for Graduate Medical Education duty hours regulations.

METHOD

In fall 2010, investigators surveyed IM and surgery program directors, assessing their views of the likely impact of the 2011 duty hours standards on learning environment, workload, education opportunities, program administration, and patient outcomes.

RESULTS

Of 381 IM program directors, 287 (75.3%) responded; of 225 surgery program directors, 118 (52.4%) responded. Significantly more surgeons than internists indicated that the new regulations would likely negatively impact learning climate, including faculty morale and residents' relationships (P < .001). Most leaders in both specialties (80.8% IM, 80.2% surgery) felt that the regulations would likely increase faculty workload (P = .73). Both IM (82.2%) and surgery (96.6%) leaders most often rated, of all education opportunities, first-year resident clinical experience to be adversely affected (P < .001). Respondents from both specialties indicated that they will hire more nonphysician/midlevel providers (59.5% IM, 89.0% surgery, P < .001) and use more nonteaching services (66.8% IM, 70.1% surgery, P = .81). Respondents expect patient safety (45.1% IM, 76.9% surgery, P < .001) and continuity of care (83.6% IM across all training levels, 97.5% surgery regarding first-year residents) to decrease.

CONCLUSIONS

IM and surgery program directors agree that the 2011 duty hours regulations will likely negatively affect the quality of the learning environment, workload, education opportunities, program administration, and patient outcomes. Careful evaluation of actual impact is important.

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009

PURPOSE

To gauge internal medicine (IM) trainees' perceptions regarding aspects of their inpatient rotations, including supervision, educational opportunities, the perceived effect of duty hours regulations on quality of patient care, the causes of medical errors, and sleep.

METHOD

The authors analyzed the results of questionnaires administered to trainees following the October 2009 in-training examinations (ITE).

RESULTS

Of the 21,768 IM trainees in postgraduate years 1 through 3 who took the IM-ITE, 18,272 (83.9%) responded. The majority of these trainees (87.7%) reported that supervision was adequate, and nearly half (46.3%) reported insufficient or minimal time to participate in learning activities. Two-thirds or more thought that specific work regulations such as limited shift length and more time off after nights and extended shifts would at least "occasionally," if not "usually" or "always," improve patient care. IM trainees at least "occasionally" attributed errors to workload (68.8% of respondents), fatigue (66.9%), inexperience or lack of knowledge (61.0%), incomplete handoffs (60.2%), and insufficient ancillary staff (53.5%). IM trainees' sleep hours were limited during extended and overnight shifts.

CONCLUSIONS

IM trainees agree that limited educational opportunities are the weakest part of the average inpatient rotation. Few have complaints about the adequacy of supervision. These trainees' optimism regarding the positive influence of potential work hours restrictions on patient care and their views of likely causes of medical errors suggest the need for innovative patient care schedules and education curricula.

Duty hours, quality of care, and patient safety: general surgery resident perceptions

BACKGROUND

The balance between patient treatment risks and training residents to proficiency is confounded by duty-hour limits. Stricter limits have been recommended to enhance quality and safety, although supporting data are scarce.

STUDY DESIGN

A previously piloted survey was delivered with the 2010 American Board of Surgery In-Training Examination (ABSITE). First postgraduate year (PGY1) and PGY2 trainees took the Junior examination (IJE); PGY3 and above took the Senior examination (ISE). Residency type, size, and location were linked to examinees using program codes. Five survey items queried all residents about the impact of further hour limits on care quality; online test residents answered 7 more items probing medical error sources. Data were analyzed using factorial ANOVA for association with sex, PGY level, and program demographics.

RESULTS

There were 6,161 categorical surgery residents who took the ABSITE: 60% men, 60% ISE, and two-thirds in university programs. Paper (n = 5,079) and online (n = 1,082) examinees were similar. Item response rates ranged from 91% to 98%. Few (<25%) perceived that stricter hour limits would improve care quality to a large or maximal extent. IJE plus West and Northeast residents significantly more often favored fewer hours. Factors perceived as contributing to medical errors usually or always by ≥ 15% of residents were incomplete handoffs, inexperience or lack of knowledge, insufficient ancillary personnel, and excessive workload.

CONCLUSIONS

Most categorical surgery residents do not perceive that reduced duty hours will noticeably improve quality of care. Resident perceptions of causes of medical errors suggest that system changes are more likely to enhance patient safety than further hour limits.

Perspective: Resident physician wellness: a new hope

Residency training is a challenging period in a physician's career owing to a multitude of stressors perhaps not previously encountered. In some cases, these stressors may culminate in a state of burnout. In response, much has been written about the issues of personal wellness during residency training. Recently, duty hours reform has been the major focus of addressing resident wellness; however, this intervention has established little benefit and has created unintended negative consequences. Alternatively, an emerging solution may be the implementation of resident wellness programs into residency training. Such programs are defined by a combination of active and passive initiatives targeting the various domains of physical, mental, social, and intellectual wellness. In contrast to duty hours reform, resident wellness programs are generally free from controversy and have been shown to improve resident wellness and enhance empathy.This article highlights the salient causes of burnout as it applies to present-day resident physicians and the patient care they provide. Moreover, in the wake of the controversy surrounding duty hours reform, a novel approach to resident wellness involving structured resident wellness programs is discussed. Specifically included are the fundamental components of a wellness program, the advantages held over duty hours reform, methods to evaluate program efficacy, and the current evidence to support these initiatives. Formal wellness curricula, including an evaluative process, should be an integral component of physician training. These programs represent a new hope in the solution to the long-debated issue of burnout and wellness during residency training.