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Weaver MD, Sullivan JP, Landrigan CP, Barger LK. Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk. Jt Comm J Qual Patient Saf 2023; 49:634-647. [PMID: 37543449 DOI: 10.1016/j.jcjq.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
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.
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Mariathas HH, Hurley O, Anaraki NR, Young C, Patey C, Norman P, Aubrey-Bassler K, Wang PP, Gadag V, Nguyen HV, Etchegary H, McCrate F, Knight JC, Asghari S. A Quality Improvement Emergency Department Surge Management Platform (SurgeCon): Protocol for a Stepped Wedge Cluster Randomized Trial. JMIR Res Protoc 2022; 11:e30454. [PMID: 35323121 PMCID: PMC8990381 DOI: 10.2196/30454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite many efforts, long wait times and overcrowding in emergency departments (EDs) have remained a significant health service issue in Canada. For several years, Canada has had one of the longest wait times among the Organisation for Economic Co-operation and Development countries. From a patient's perspective, this challenge has been described as "patients wait in pain or discomfort for hours before being seen at EDs." To overcome the challenge of increased wait times, we developed an innovative ED management platform called SurgeCon that was designed based on continuous quality improvement principles to maintain patient flow and mitigate the impact of patient surge on ED efficiency. The SurgeCon quality improvement intervention includes a protocol-driven software platform, restructures ED organization and workflow, and aims to establish a more patient-centric environment. We piloted SurgeCon at an ED in Carbonear, Newfoundland and Labrador, and found that there was a 32% reduction in ED wait times. OBJECTIVE The primary objective of this trial is to determine the effects of SurgeCon on ED performance by assessing its impact on length of stay, the time to a physician's initial assessment, and the number of patients leaving the ED without being seen by a physician. The secondary objectives of this study are to evaluate SurgeCon's effects on patient satisfaction and patient-reported experiences with ED wait times and its ability to create better-value care by reducing the per-patient cost of delivering ED services. METHODS The implementation of the intervention will be assessed using a comparative effectiveness-implementation hybrid design. This type of hybrid design is known to shorten the amount of time associated with transitioning interventions from being the focus of research to being used for practice and health care services. All EDs with 24/7 on-site physician support (category A hospitals) will be enrolled in a 31-month, pragmatic, stepped wedge cluster randomized trial. All clusters (hospitals) will start with a baseline period of usual care and will be randomized to determine the order and timing of transitioning to intervention care until all hospitals are using the intervention to manage and operationalize their EDs. RESULTS Data collection for this study is continuing. As of February 2022, a total of 570 randomly selected patients have participated in telephone interviews concerning patient-reported experiences and patient satisfaction with ED wait times. The first of the 4 EDs was randomly selected, and it is currently using SurgeCon's eHealth platform and applying efficiency principles that have been learned through training since September 2021. The second randomly selected site will begin intervention implementation in winter 2022. CONCLUSIONS By assessing the impact of SurgeCon on ED services, we hope to be able to improve wait times and create better-value ED care in this health care context. TRIAL REGISTRATION ClinicalTrials.gov NCT04789902; https://clinicaltrials.gov/ct2/show/NCT04789902. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/30454.
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Affiliation(s)
- Hensley H Mariathas
- Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Oliver Hurley
- Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Nahid Rahimipour Anaraki
- Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Christina Young
- Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Christopher Patey
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.,Eastern Health, Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear General Hospital, Carbonear, NL, Canada
| | - Paul Norman
- Eastern Health, Carbonear Institute for Rural Reach and Innovation by the Sea, Carbonear General Hospital, Carbonear, NL, Canada
| | - Kris Aubrey-Bassler
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Peizhong Peter Wang
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Veeresh Gadag
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Holly Etchegary
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Farah McCrate
- Department of Research and Innovation, Eastern Health, St. John's, NL, Canada
| | - John C Knight
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.,Newfoundland and Labrador Centre for Health Information, St. John's, NL, Canada
| | - Shabnam Asghari
- Centre for Rural Health Studies, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
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Awan M, Zagales I, McKenney M, Kinslow K, Elkbuli A. ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review. JOURNAL OF SURGICAL EDUCATION 2021; 78:e35-e46. [PMID: 34183278 DOI: 10.1016/j.jsurg.2021.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Muhammad Awan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Israel Zagales
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; University of South Florida, Tampa, Florida
| | - Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida.
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Matsushima K, Inaba K, Skiada D, Esparza M, Cho J, Lee T, Strumwasser A, Magee G, Grabo D, Lam L, Benjamin E, Belzberg H, Demetriades D. A high-volume trauma intensive care unit can be successfully staffed by advanced practitioners at night. J Crit Care 2016; 33:4-7. [PMID: 26928304 DOI: 10.1016/j.jcrc.2016.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/21/2015] [Accepted: 01/18/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE It remains unknown whether critically ill trauma patients can be successfully managed by advanced practitioners (APs). The purpose of this study was to examine the impact of night coverage by APs in a high-volume trauma intensive care unit (ICU) on patient outcomes and care processes. MATERIALS AND METHODS During the study period, our ICU was staffed by APs during the night shift (7 pm-7 am) from Sunday to Wednesday and by resident physicians (RPs) from Thursday to Saturday. On-call trauma fellows and attending surgeons in house supervised both APs and RPs. Patient outcomes and care processes by APs was compared with those admitted by RPs. RESULTS A total of 289 patients were identified between July 2013 and February 2014. Median lactate clearance rate within 24 hours of admission was similar between study groups (10.0% vs 9.1%; P = .39). Advanced practitioners and RPs transfused patients requiring massive transfusion with a similar blood product ratio (packed red blood cell:fresh frozen plasma) (2.1:1 vs 1.7:1; P = .32). In a multiple logistic regression analysis, AP coverage was not associated with any clinical outcome differences. CONCLUSIONS Our data suggest that, with adequate supervision, a high-volume trauma ICU can be safely staffed by APs overnight.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA.
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Dimitra Skiada
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Michael Esparza
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Jayun Cho
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Tim Lee
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Aaron Strumwasser
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Gregory Magee
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Daniel Grabo
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Lydia Lam
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Elizabeth Benjamin
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
| | - Howard Belzberg
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA
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