Impact of the 2011 ACGME resident duty hour reform on hospital patient experience and processes-of-care

ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review

OBJECTIVE

The ACGME instituted the 2011 residency duty-hour restrictions (DHR) to increase resident well-being and patient safety. However, its eventual remodeling came after patient care was deemed unaffected. We aimed to identify the effects of the ACGME 2011-DHR on (1) patient outcomes, (2) surgical resident case volume, and (3) surgical resident quality of life.

DESIGN

Literature search using Google Scholar, PubMed, Cochrane, and Embase for publications between 2010 and 2020, on the 2011-DHR effects on resident and patient outcomes. Studies containing the number of cases performed during training, quality of life, and surgical patients' outcomes were included.

RESULTS

Fifteen studies met inclusion criteria. There was no difference in complication rates for surgical patients post 2011-DHR (p = 0.561). 2011-DHR caused surgical caseload shifts from interns to senior residents reflected by decreased operative cases for interns (p = 0.005) with significantly more total cases performed by chief residents (p = 0.0006). Pre-2011-DHR had more work flexibility that led to higher resident well-being (p = 0.01). Only 25% of residents approved of the 2011-DHR while 87% felt these restrictions would have adverse effects.

CONCLUSION

Current literature supports that the 2011-DHR did not improve patient outcomes, decreased surgical experience for junior residents and shifted clinical responsibilities to senior residents. System wide regulations such as the 2011-DHR may unintentionally create professional and personal life imbalance and introduce stress over resident inability to perform clinical responsibilities. Future systemic interventions to address resident well-being should be made with caution and not solely limited to the number of hours they work in a single week or in a single shift.

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.

Progression of Emergency Medicine Resident Patient Experience Scores by Level of Training

Background:

Patient satisfaction surveys are vital to measuring a patient’s experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known.

Objectives:

To evaluate whether EM residents’ patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement.

Methods:

A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 “physician questions” and the “overall” score.

Results:

We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident.

Conclusion:

We did not observe a difference in EM residents’ patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.

Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood.

OBJECTIVE

We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals.

METHODS

A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs.

RESULTS

We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P = .026) at teaching relative to nonteaching hospitals.

CONCLUSIONS

There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

ACGME Clinical and Educational Work Hour Standards: Perspectives and Recommendations from Emergency Medicine Educators

Introduction

The American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical Education’s (ACGME) Second Resident Duty Hours in the Learning and Working Environment Congress. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony.

Methods

In 2016 our joint working group of experts in EM medical education conducted a consensus-based, mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv.

Results

A total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions, organizational recommendations were crafted and submitted to the ACGME.

Conclusion

EM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.