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.

Evaluating the Impact of ACGME Resident Duty Hour Restrictions on Patient Outcomes for Bilateral Breast Reductions

The Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions limiting residents to 80 hours per week in 2003 and further extended restrictions in 2011 to improve resident and patient well-being. Numerous studies have examined the effects of these restrictions on patient outcomes with inconclusive results. Few efforts have been made to examine the impact of this reform on the safety of common plastic surgery procedures. This study seeks to assess the influence of ACGME duty-hour restrictions on patient outcomes, using bilateral breast reduction mammoplasty as a marker for resident involvement and operative autonomy.

Methods

Bilateral breast reductions performed in the 3 years before and after each reform were collected from the National Inpatient Sample database: pre-duty hours (2000-2002), duty hours (2006-2008), and extended duty hours (2012-2014). Multivariable logistic regression models were constructed to investigate the association between ACGME duty hour restrictions on medical and surgical complications.

Results

Overall, 19,423 bilateral breast reductions were identified. Medical and surgical complication rates in these patients increased with each successive iteration of duty hour restrictions (P < 0.001). The 2003 duty-hour restriction independently associated with increased surgical (OR = 1.51, P < 0.001) and medical complications (OR = 1.85, P < 0.001). The 2011 extended duty-hour restriction was independently associated with increased surgical complications (OR = 1.39, P < 0.001).

Conclusions

ACGME duty-hour restrictions do not seem associated with better patient outcomes for bilateral breast reduction although there are multiple factors involved. These considerations and consequences should be considered in decisions that affect resident quality of life, education, and patient safety.

Physiological Responses and Training Satisfaction During National Rollout of a Neurosurgical Intraoperative Catastrophe Simulator for Resident Training

BACKGROUND

Systematic use of neurosurgical training simulators across institutions is significantly hindered by logistical and financial constraints.

OBJECTIVE

To evaluate feasibility of large-scale implementation of an intraoperative catastrophe simulation, we introduced a highly portable and low-cost immersive neurosurgical simulator into a nationwide curriculum for neurosurgery residents, during years 2016 to 2019.

METHODS

The simulator was deployed at 9 Society of Neurological Surgeons junior resident courses and a Congress of Neurological Surgeons education course for a cohort of 526 residents. Heart rate was tracked to monitor physiological responses to simulated stress. Experiential survey data were collected to evaluate simulator fidelity and resident attitudes toward simulation.

RESULTS

Residents rated the simulator positively with a statistically significant increase in satisfaction over time accompanying refinements in the simulator model and clinical scenario. The simulated complications induced stress-related tachycardia in most participants (n = 249); however, a cohort of participants was identified that experienced significant bradycardia (n = 24) in response to simulated stress.

CONCLUSION

Incorporation of immersive neurosurgical simulation into the US national curriculum is logistically feasible and cost-effective for neurosurgical learners. Participant surveys and physiological data suggest that the simulation model recreates the situational physiological stress experienced during practice in the live clinical environment. Simulation may provide an opportunity to identify trainees with maladaptive responses to operative stress who could benefit from additional simulated exposure to mitigate stress impacts on performance.

Optimizing the patient handoff and progress note documentation efficiency in the EPIC EMR system within a neurosurgery residency: A quality improvement initiative

BACKGROUND

Handoffs and documentation are a potentially modifiable source of medical error. However, little attention has been given toenhancementof these within the neurosurgical field. We aim to increase efficiency and accuracy of neurosurgical handoffs, including the neurological exam, thus decreasing medical documentation time within current duty-hour restrictions.

METHODS

The existing Epic electronic medical record system was modified to include the neurological exam in the handoff: a tool used to generate lists including relevant patient clinical details and plans. The handoff tool was also converted into a subjective, objective, assessment, and plan (SOAP) format, which was leveraged to efficiently generate daily progress notes. A four-question survey was developed to assess the effectiveness of this new format. Mean note times were compared before and after the EPIC update using an independent samples t-test.

RESULTS

All of the surveyed neurosurgery residents at our institution reported a decrease in documentation time per progress note, felt the notes were more accurate, and found it easier to recall the neurological exams of patients. 8/9 residents felt that the new handoff made in-house call less stressful. There was a significant difference in mean note time, with the mean note time of 37.9 s after the EPIC upgrade compared to 120 s prior the upgrade. We project that over 241 h of documentation will be saved annually at our institution.

CONCLUSIONS

This QI project demonstrates how a low-effort initiative improved resident recall of patients' neurological exams while saving time spent documenting daily progress notes.

Resources for Operative Neurosurgical Education Among Trainees in the Philippines

BACKGROUND

Operative neurosurgical skills education is a vital part of neurosurgical training, and these skills are usually obtained through operating room experience and supplemented by textbooks and other resources. We aimed to determine the resources used by trainees in the Philippines, both prior to and after the onset of the coronavirus disease 2019 pandemic.

METHODS

An online survey was sent to neurosurgical trainees in the Philippines from January to March 2021. Data on demographics, educational resources used, and weekly hours spent on each were collected, for both the pre- and post-coronavirus disease 2019 periods.

RESULTS

A total of 37 neurosurgical trainees (60% response rate) participated in the survey. Most respondents were female (70%), in their senior levels (58%), and undergoing training in a public institution (65%). The main resources for operative neurosurgical education were operative experience, online academic resources, and neurosurgical textbooks. After the onset of the pandemic, the overall time spent decreased to 61.2 hours/week from 67.7 hours/week, with a significant reduction in the hours spent on operative experience (27.3 vs. 21.3 hours/week, P < 0.0001) and a significant increase in the time spent on webinars (0 vs. 3.2 hours/week, P < 0.0001) and online resources as a whole (14.9 vs. 16.4 hours/week, P = 0.0003).

CONCLUSIONS

Operative experience, online academic resources, and neurosurgical textbooks were the main resources for operative neurosurgical education among trainees in the Philippines. After the onset of the pandemic, the hours spent on operative experience decreased and online academic resources increased significantly. New avenues of neurosurgical education, particularly webinars, also became available locally.

Paving the Path to Wellness: A Systematic Review of Wellness Programs for Neurosurgery Trainees

BACKGROUND

Neurosurgical trainees have a heavy workload and poor quality of life, resulting in high rates of burnout and attrition. Consequently, wellness programs have been used by various training institutions to combat this situation.

OBJECTIVE

We aimed to identify and describe wellness programs available for neurosurgical trainees in their training institutions, the outcome measures used to assess them, and their efficacy.

METHODS

A systematic review of the literature was made following PRISMA guidelines.

RESULTS

Six studies were included in the review, describing wellness programs from 9 institutions. All programs except 1 used exercise as the core component. The other components included physical and mental well-being lectures, team-building activities, and cultural excursions. Most institutions used piloted satisfaction and perception questionnaires to assess efficacy. Trainee perceptions of wellness programs were generally positive, but the responses on validated questionnaires and surveys were mixed. Barriers to the program included lack of institutional support, time constraints, fatigue, and feelings of guilt in prioritizing wellness over patient care.

CONCLUSIONS

There is a paucity of literature regarding trainee wellness in neurosurgery. A few training programs have instituted wellness initiatives for trainees, and the feedback was generally positive. However, objective measures of efficacy such as validated questionnaires and scales yielded mixed results.

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.

Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work

BACKGROUND

The association between long work hours and outcomes among attending surgeons remains an issue of debate.

OBJECTIVE

To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons.

METHODS

We executed a cohort study with unruptured cerebral aneurysm patients, who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis.

RESULTS

Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. There was no difference in inpatient mortality (adjusted difference, -0.7%; 95% confidence interval [CI], -1.4% to 0.02%), discharge to a facility (adjusted difference, -0.1%; 95% CI, -1.2% to 1.2%), or length of stay (adjusted difference, -0.58; 95% CI, -1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not.

CONCLUSION

Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences in mortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.

Perceived Preparedness of Facial Plastic Surgery Fellows Over Time: A Survey of AAFPRS Fellowship Directors

OBJECTIVE

Assess the effects of American Council for Graduate Medical Education (ACGME) resident work hour restrictions on the preparedness of incoming facial plastic surgery fellows as assessed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) fellowship directors.

METHODS

Observational survey study evaluating the perception of ACGME resident duty hour change on resident surgical and clinical skills from fellowship directors of AAFPRS fellowship programs in the US. A cross-sectional survey was sent to 47 fellowship directors of AAFPRS fellowship programs. Perceived change in resident clinical and surgical skills were measured using a 5-point Likert scale (1 = significantly improved, 2 = improved, 3 = neither improved nor worsened, 4 = worsened, 5 = significantly worsened) to evaluate 15 benchmarks.

RESULTS

Responses received from 36 fellowship directors. The results indicate no statistically significant perceived trend of ACGME duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, cohort analysis demonstrated that fellowship directors with more than 10 years of service perceived a more negative impact in 2 clinical benchmarks (assessment/planning and basic exposure) over time.

CONCLUSIONS

The study results appear to show no significant perceived trend over time on the effect of duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, there are some apparent opinion differences between fellowship directors separated by years of service, with more negative perceptions noted in 2 clinical areas by those with more than 10 years of service. This study is in line with the more recent literature that suggests a trend toward a less negative perception of the duty hour change. This may suggest resident education is adapting to the ACGME duty hour regulations.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures

OBJECTIVES/HYPOTHESIS

To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation.

STUDY DESIGN

Retrospective database review.

METHODS

The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ² and binary logistic regression analyses.

RESULTS

In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450).

CONCLUSIONS

In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2804-2810, 2018.

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

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

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

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

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

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

Effects of transcranial direct-current stimulation on laparoscopic surgical skill acquisition

Background

Changes in medical education may limit opportunities for trainees to gain proficiency in surgical skills. Transcranial direct-current stimulation (tDCS) can augment motor skill learning and may enhance surgical procedural skill acquisition. The aim of this study was to determine the effects of tDCS on simulation-based laparoscopic surgical skill acquisition.

Methods

In this double-blind, sham-controlled randomized trial, participants were randomized to receive 20 min of anodal tDCS or sham stimulation over the dominant primary motor cortex, concurrent with Fundamentals of Laparoscopic Surgery simulation-based training. Primary outcomes of laparoscopic pattern-cutting and peg transfer tasks were scored at baseline, during repeated performance over 1 h, and again at 6 weeks. Intent-to-treat analysis examined the effects of treatment group on skill acquisition and retention.

Results

Of 40 participants, those receiving tDCS achieved higher mean(s.d.) final pattern-cutting scores than participants in the sham group (207·6(30·0) versus 186·0(32·7) respectively; P = 0·022). Scores were unchanged at 6 weeks. Effects on peg transfer scores were not significantly different (210·2(23·5) in the tDCS group versus 201·7(18·1) in the sham group; P = 0·111); the proportion achieving predetermined proficiency levels was higher for tDCS than for sham stimulation. Procedures were well tolerated with no serious adverse events and no decreases in motor measures.

Conclusion

The addition of tDCS to laparoscopic surgical training may enhance skill acquisition. Trials of additional skills and translation to non-simulated performance are required to determine the potential value in medical education and impact on patient outcomes. Registration number: NCT02756052 (https://clinicaltrials.gov/).

Establishment of Next-Generation Neurosurgery Research and Training Laboratory with Integrated Human Performance Monitoring

Quality of neurosurgical care and patient outcomes are inextricably linked to surgical and technical proficiency and a thorough working knowledge of microsurgical anatomy. Neurosurgical laboratory-based cadaveric training is essential for the development and refinement of technical skills before their use on a living patient. Recent biotechnological advances including 3-dimensional (3D) microscopy and endoscopy, 3D printing, virtual reality, surgical simulation, surgical robotics, and advanced neuroimaging have proved to reduce the learning curve, improve conceptual understanding of complex anatomy, and enhance visuospatial skills in neurosurgical training. Until recently, few means have allowed surgeons to obtain integrated surgical and technological training in an operating room setting. We report on a new model, currently in use at our institution, for technologically integrated surgical training and innovation using a next-generation microneurosurgery skull base laboratory designed to recreate the setting of a working operating room. Each workstation is equipped with a 3D surgical microscope, 3D endoscope, surgical drills, operating table with a Mayfield head holder, and a complete set of microsurgical tools. The laboratory also houses a neuronavigation system, a surgical robotic, a surgical planning system, 3D visualization, virtual reality, and computerized simulation for training of surgical procedures and visuospatial skills. In addition, the laboratory is equipped with neurophysiological monitoring equipment in order to conduct research into human factors in surgery and the respective roles of workload and fatigue on surgeons' performance.

Association of Otolaryngology Resident Duty Hour Restrictions With Procedure-Specific Outcomes in Head and Neck Endocrine Surgery

Importance

Graduate medical education has undergone a transformation from traditional long work hours to a restricted plan to allow adequate rest for residents. The initial goal of this restriction is to improve patient outcomes.

Objective

To determine whether duty hour restrictions had any impact on surgery-specific outcomes by analyzing complications following thyroid and parathyroid procedures performed before and after duty hour reform.

Design, Setting, and Participants

Retrospective cross-sectional analysis of the National Inpatient Sample (NIS).The NIS was queried for procedure codes associated with thyroid and parathyroid procedures for the years 2000 to 2002 and 2006 to 2008. Hospitals were divided based on teaching status into 3 groups: nonteaching hospitals (NTHs), teaching hospitals without otolaryngology programs (THs), and teaching hospitals with otolaryngology programs (THs-OTO).

Main Outcomes and Measures

Procedure-specific complication rates, length of stay, and mortality rates were collected. SAS statistical software (version 9.4) was used for analysis with adjustment using Charlson comorbidity index.

Results

Total numbers of head and neck endocrine procedures were 34 685 and 39 770 (a 14.7% increase), for 2000 to 2002 and 2006 to 2008, respectively. THs-OTO contributed a greater share of procedures in 2006 to 2008 (from 18% to 25%). With the earlier period serving as the reference, length of stay remained constant (2.1 days); however, total hospital charges increased (from $12 978 to $23 708; P < .001). Rates of postoperative hematoma (odds ratio [OR], 1.21; 95% CI, 1.06-1.38), hypoparathyroidism (OR, 1.27; 95% CI, 1.06-1.52), and unintentional vessel lacerations (OR, 1.36; 95% CI, 1.02-1.83) increased overall with NTHs (OR, 1.26; 95% CI, 1.04-1.52), THs (OR, 1.65; 95% CI, 1.15-2.37), and THs-OTO (OR, 1.98; 95% CI, 1.09-3.61) accounting for these differences, respectively. Overall mortality decreased (OR, 0.66; 95% CI, 0.47-0.94) following a decrease in the TH-OTO mortality rate (OR, 0.34; 95% CI, 0.12-0.93).

Conclusions and Relevance

While recurrent laryngeal nerve injury, hematoma formation, and hypoparathyroidism did not change, length of stay and mortality improved within THs-OTO following head and neck endocrine procedures after implementation of duty hour regulations. This finding refutes the concern that duty hour restrictions result in poorer overall outcomes. Less time available to develop technical competence may play a factor in some outcomes in lieu of recurrent laryngeal nerve injury increasing within THs and accidental injury to vessels, organs, or nerves and hypocalcemia increasing within THs-OTO. Furthermore, head and neck endocrine cases increased at THs with otolaryngology programs.

Impact of the 2003 ACGME Resident Duty Hour Reform on Hospital-Acquired Conditions: A National Retrospective Analysis

BACKGROUND

The Accreditation Council for Graduate Medical Education reforms in 2003 instituted an 80-hour weekly limit for resident physicians. Critics argue that these restrictions have increased handoffs among residents and the potential for a decline in patient safety. "Never events" hospital-acquired conditions (HACs) are a set of preventable events used as a quality metric in hospital safety analyses.

OBJECTIVE

This analysis evaluated post-work hour reform effects on HAC incidence for US hospital inpatients, using the National Inpatient Sample.

METHODS

Data were collected from 2000-2002 (pre-2003) and 2004-2006 (post-2003) time periods. HAC incidence in academic and non-academic centers was evaluated in multivariate analysis assessing for likelihood of HAC occurrence, prolonged length of stay (pLOS), and increased total charges.

RESULTS

The data encompassed approximately 111 million pre-2003 and 117 million post-2003 admissions. Patients were 10% more likely to incur a HAC in the post-2003 versus pre-2003 era (odds ratio [OR] = 1.10; 95% confidence interval [CI] 1.06-1.14; P < .01). Teaching hospitals exhibited an 18% (OR = 1.18; 95% CI 1.11-1.27; P < .01) increase in HAC likelihood, with no change in nonteaching settings (OR = 1.03; 95% CI 1.00-1.06; P > .05). Patients with ≥ 1 HAC were associated with a 60% likelihood of elevated charges (OR = 1.60; 95% CI 1.50-1.72; P < .01) and 65% likelihood of pLOS (OR = 1.65; 95% CI 1.60-1.70; P < .01).

CONCLUSIONS

Post-2003 era patients were associated with 10% increased likelihood of HAC, with effects noted primarily at teaching hospitals.

Effect of Home-Call on Otolaryngology Resident Education: A Pilot Study

OBJECTIVE

To inform institutional policies regarding call encounters through an evaluation of the effect of home-call on academic experience and fatigue among surgical residents. This study conducted an assessment of the nature of resident call encounters premidnight and postmidnight and a comparative analysis of sleep deprivation and efficiency in residents during home-call and off call.

DESIGN, SETTING, AND PARTICIPANTS

All Otolaryngology-Head and Neck Surgery residents (n = 9) at single Canadian institution were asked to establish the time and nature of call encounters during home-call. Residents completed the Stanford Sleepiness Scale precall and postcall to measure sleepiness and wore an Actigraph device to measure sleep efficiency to establish fatigue in the setting of home-call as compared with residents off call. Home-call and off call patterns were studied using a random computer-generated selection of days for participants in both study groups. Analysis was conducted from December 1, 2013 to December 30, 2014.

RESULTS

Residents received on average 7 pages per night, of which 78.5% of pages were for nonurgent issues. On an average, change in sleep deprivation scores postcall was 3.0 points higher (95% CI: 2.48-3.57, p < 0.0001) in residents who were qualified for a postcall day compared with residents who did not qualify for a postcall day and residents off call according to the Stanford Sleepiness Scale. Postcall sleep deprivation was significantly associated with number of encounters managed after midnight, regardless of management through telephone or in-hospital (p = 0.01). The Actigraph device identified a significant decrease in sleep efficiency in residents who were qualified for a postcall day compared with residents off call (mean = -31.1; 95% CI: -38.9, -23.4; p < 0.001).

CONCLUSIONS

This is the first study to evaluate surgical residents' home-call experience. We identified a high proportion of nonurgent encounters that residents managed on call and increased postcall fatigue associated with postmidnight telephone encounters. This study highlights the detrimental effects of frequent sleep interruptions because of encounters on call and suggests the need for institutional guidelines to help minimize these interruptions.

The 2016 AANS Presidential Address: Leading the way

This AANS presidential address focuses on enduring values of the neurosurgical profession that transcend the current political climate. The address was delivered by Dr. Batjer during a US presidential election year, but the authors have intentionally avoided discussing the current chaos of the American health care system in the knowledge that many pressing issues will change depending on the outcome of the 2016 elections. Instead, they have chosen to focus on clarifying what neurosurgeons, and the American Association of Neurological Surgeons, in particular, stand for; identifying important challenges to these fundamental principles and values; and proposing specific actions to address these challenges. The authors cite "de-professionalism" and commoditization of medicine as foremost among the threats that confront medicine and surgery today and suggest concrete action that can be taken to reverse these trends as well as steps that can be taken to address other significant challenges. They emphasize the importance of embracing exceptionalism and never compromising the standards that have characterized the profession of neurosurgery since its inception.

Residency program trainee-satisfaction correlate with results of the European board examination in neurosurgery

INTRODUCTION

Substantial country differences in neurosurgical training throughout Europe have recently been described, ranging from subjective rating of training quality to objective working hours per week. The aim of this study was to analyse whether these differences translate into the results of the written and oral part of the European Board Examination in Neurological Surgery (EBE-NS).

METHODS

Country-specific composite scores for satisfaction with quality of theoretical and practical training, as well as working hours per week, were obtained from an electronic survey distributed among European neurosurgical residents between June 2014 and March 2015. These were related to anonymous country-specific results of the EBE-NS between 2009 and 2016, using uni- and multivariate linear regression analysis.

RESULTS

A total of n = 1025 written and n = 63 oral examination results were included. There was a significant linear relationship between the country-specific EBE-NS result in the written part and the country-specific composite score for satisfaction with quality of theoretical training [adjusted regression coefficient (RC) -3.80, 95 % confidence interval (CI) -5.43-7 -2.17, p < 0.001], but not with practical training or working time. For the oral part, there was a linear relationship between the country-specific EBE-NS result and the country-specific composite score for satisfaction with quality of practical training (RC 9.47, 95 % CI 1.47-17.47, p = 0.021), however neither with satisfaction with quality of theoretical training nor with working time.

CONCLUSION

With every one-step improvement on the country-specific satisfaction score for theoretical training, the score in the EBE-NS Part 1 increased by 3.8 %. With every one-step improvement on the country-specific satisfaction score for practical training, the score in the EBE-NS Part 2 increased by 9.47 %. Improving training conditions is likely to have a direct positive influence on the knowledge level of trainees, as measured by the EBE-NS. The effect of the actual working time on the theoretical and practical knowledge of neurosurgical trainees appears to be insignificant.

Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

BACKGROUND

The impact of the 2003 residency duty hour reform on patient care remains a debated issue.

OBJECTIVE

Determine the association between duty hour limits and mortality in patients with nervous system pathology.

METHODS

Via a retrospective cohort study using the Nationwide Inpatient Sample from 2000-2010, the authors evaluated in-hospital mortality status in those with a primary discharge level diagnosis of disease or disorder of the nervous system. Odds ratios were calculated, and Bonferroni corrected P values and confidence intervals were determined to account for multiple comparisons relating in-hospital mortality with teaching status of the hospital by year.

RESULTS

The pre-reform (2000-2002) and peri-reform (2003) periods revealed no significant difference between teaching and nonteaching hospital mortality (P > .99). The post-reform period (2004-2010) was dominated by years of significantly higher mortality rates in teaching hospitals compared to nonteaching hospitals: 2004 (P < .001); 2006 (P = .043); 2007 (P = .042); and 2010 (P = .003). However, data for 2005 (P ≥ .99), 2008 (P = .80), and 2009 (P = .09) did not show a significant difference in mortality.

CONCLUSIONS

Teaching and nonteaching hospital mortality was similar in patients with nervous system pathology prior to the duty hour reform. While nonteaching institutions demonstrated steadily declining mortality over the decade, teaching hospital mortality spiked in 2004 and declined at a more restricted rate. The timing of these changes could suggest a negative correlation of duty hour restrictions on outcomes of patients with nervous system pathology.

Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience

OBJECTIVE Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital. METHODS The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders. RESULTS A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35). CONCLUSIONS This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

Effect of resident handoffs on length of hospital and intensive care unit stay in a neurosurgical population: a cohort study

OBJECT

Handoffs and services changes are potentially modifiable sources of medical error and delays in transition of care. This cohort study assessed the relationship between resident service handoffs and length of stay for neurosurgical patients.

METHODS

All patients admitted to the University of Alabama at Birmingham neurosurgical service between July 1, 2012, and July 1, 2014, were retrospectively identified. A service handoff was defined as any point when a resident handed off coverage of a service for longer than 1 weekend. A conditional probability distribution was constructed to adjust length of stay for the increasing probability of a random handoff. The Student t-test and ANCOVA were used to assess relationships between resident service handoffs and length of hospital stay, adjusted for potential confounders.

RESULTS

A total of 3038 patients met eligibility criteria and were included in the statistical analyses. Adjusted length of hospital stay (5.32 vs 3.53 adjusted days) and length of ICU stay (4.38 vs 2.96 adjusted days) were both longer for patients who experienced a service handoff, with no difference in mortality. In the ANCOVA model, resident service handoff remained predictive of both length of hospital stay (p < 0.001) and length of ICU stay (p < 0.001).

CONCLUSIONS

Occurrence of a resident service handoff is an independent predictor of length of hospital and ICU stay in neurosurgical patients. This finding is novel in the neurosurgical literature. Future research might identify mechanisms for improving continuity of care and mitigating the effect of resident handoffs on patient outcomes.

Usefulness of a Virtual Reality Percutaneous Trigeminal Rhizotomy Simulator in Neurosurgical Training

BACKGROUND

Simulation-based training may be incorporated into neurosurgery in the future.

OBJECTIVE

To assess the usefulness of a novel haptics-based virtual reality percutaneous trigeminal rhizotomy simulator.

METHODS

A real-time augmented reality simulator for percutaneous trigeminal rhizotomy was developed using the ImmersiveTouch platform. Ninety-two neurosurgery residents tested the simulator at American Association of Neurological Surgeons Top Gun 2014. Postgraduate year (PGY), number of fluoroscopy shots, the distance from the ideal entry point, and the distance from the ideal target were recorded by the system during each simulation session. Final performance score was calculated considering the number of fluoroscopy shots and distances from entry and target points (a lower score is better). The impact of PGY level on residents' performance was analyzed.

RESULTS

Seventy-one residents provided their PGY-level and simulator performance data; 38% were senior residents and 62% were junior residents. The mean distance from the entry point (9.4 mm vs 12.6 mm, P = .01), the distance from the target (12.0 mm vs 15.2 mm, P = .16), and final score (31.1 vs 37.7, P = .02) were lower in senior than in junior residents. The mean number of fluoroscopy shots (9.8 vs 10.0, P = .88) was similar in these 2 groups. Linear regression analysis showed that increasing PGY level is significantly associated with a decreased distance from the ideal entry point (P = .001), a shorter distance from target (P = .05), a better final score (P = .007), but not number of fluoroscopy shots (P = .52).

CONCLUSION

Because technical performance of percutaneous rhizotomy increases with training, we proposed that the skills in performing the procedure in our virtual reality model would also increase with PGY level, if our simulator models the actual procedure. Our results confirm this hypothesis and demonstrate construct validity.

Neurosurgical resident education in Europe--results of a multinational survey

INTRODUCTION

Neurosurgical training aims at educating future generations of specialist neurosurgeons and at providing the highest-quality medical services to patients. Attaining and maintaining these highest standards constitutes a major responsibility of academic or other training medical centers.

METHODS

An electronic survey was sent to European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression analysis was used to assess the effect size of the relationship between responder-specific variables (e.g., age, gender, postgraduate year (PGY), country) and the outcomes (e.g., satisfaction).

RESULTS

A total of 652 responses were collected, of which n = 532 were taken into consideration. Eighty-five percent were 26-35 years old, 76 % male, 62 % PGY 4 or higher, and 73.5 % working at a university clinic. Satisfaction rates with theoretical education such as clinical lectures (overall: 50.2 %), anatomical lectures (31.2 %), amongst others, differed largely between the EANS member countries. Likewise, satisfaction rates with practical aspects of training such as hands-on surgical experience (overall: 73.9 %), microsurgical training (52.5 %), simulator training (13.4 %), amongst others, were highly country-dependant. In general, 89.1 % of European residents carried out the first surgical procedure under supervision within the first year of training. Supervised lumbar-/cervical spine surgeries were performed by 78.2 and 17.9 % of European residents within 12 and 24 months of training, respectively, and 54.6 % of European residents operate a cranial case within the first 36 months of training. Logistic regression analysis identified countries where residents were much more or much less likely to operate as primary surgeons compared to the European average. The caseload of craniotomies per trainee (overall: 30.6 % ≥10 craniotomies/month) and spinal procedures (overall: 29.7 % ≥10 spinal surgeries/month) varied throughout the countries and was significantly associated with more advanced residency (craniotomy: OR 1.35, 95 % CI 1.18-1.53, p < 0.001; spinal surgery: OR 1.37, 95 % CI 1.20-1.57, p < 0.001).

CONCLUSIONS

Theoretical and practical aspects of neurosurgical training are highly variable throughout European countries, despite some efforts within the last two decades to harmonize this. Some countries are rated significantly above (and others significantly below) the current European average for several analyzed parameters. It is hoped that the results of this survey should provide the incentive as well as the opportunity for a critical analysis of the local conditions for all training centers, but especially those in countries scoring significantly below the European average.

On resident duty hour restrictions and neurosurgical training: review of the literature

Within neurosurgery, the national mandate of the 2003 duty hour restrictions (DHR) by the Accreditation Council for Graduate Medical Education (ACGME) has been controversial. Ensuring the proper education and psychological well-being of residents while fulfilling the primary purpose of patient care has generated much debate. Most medical disciplines have developed strategies that address service needs while meeting educational goals. Additionally, there are numerous studies from those disciplines; however, they are not specifically relevant to the needs of a neurosurgical residency. The recent implementation of the 2011 DHR specifically aimed at limiting interns to 16-hour duty shifts has proven controversial and challenging across the nation for neurosurgical residencies--again bringing education and service needs into conflict. In this report the current literature on DHR is reviewed, with special attention paid to neurosurgical residencies, discussing resident fatigue, technical training, and patient safety. Where appropriate, other specialty studies have been included. The authors believe that a one-size-fits-all approach to residency training mandated by the ACGME is not appropriate for the training of neurosurgical residents. In the authors' opinion, an arbitrary timeline designed to limit resident fatigue limits patient care and technical training, and has not improved patient safety.

Simulated ventriculostomy training with conventional neuronavigational equipment used clinically in the operating room: prospective validation study

OBJECTIVES

Simulation is gaining increasing interest as a method of delivering high-quality, time-effective, and safe training to neurosurgical residents. However, most current simulators are purpose-built for simulation, being relatively expensive and inaccessible to many residents. The purpose of this study was to provide the first comprehensive validity assessment of ventriculostomy performance metrics from the Medtronic StealthStation S7 Surgical Navigation System, a neuronavigational tool widely used in the clinical setting, as a training tool for simulated ventriculostomy while concomitantly reporting on stress measures.

DESIGN

A prospective study where participants performed 6 simulated ventriculostomy attempts on a model head with StealthStation-coregistered imaging. The performance measures included distance of the ventricular catheter tip to the foramen of Monro and presence of the catheter tip in the ventricle. Data on objective and self-reported stress and workload measures were also collected.

SETTING

The operating rooms of the National Hospital for Neurology and Neurosurgery, Queen Square, London.

PARTICIPANTS

A total of 31 individuals with varying levels of prior ventriculostomy experience, varying in seniority from medical student to senior resident.

RESULTS

Performance at simulated ventriculostomy improved significantly over subsequent attempts, irrespective of previous ventriculostomy experience. Performance improved whether or not the StealthStation display monitor was used for real-time visual feedback, but performance was optimal when it was. Further, performance was inversely correlated with both objective and self-reported measures of stress (traditionally referred to as concurrent validity). Stress and workload measures were well-correlated with each other, and they also correlated with technical performance.

CONCLUSIONS

These initial data support the use of the StealthStation as a training tool for simulated ventriculostomy, providing a safe environment for repeated practice with immediate feedback. Although the potential implications are profound for neurosurgical education and training, further research following this proof-of-concept study is required on a larger scale for full validation and proof that training translates into improved long-term simulated and patient outcomes.

Fostering and assessing professionalism and communication skills in neurosurgical education

INTRODUCTION

Incorporation of the 6 ACGME core competencies into surgical training has proven a considerable challenge particularly for the two primarily behavioral competencies, professionalism and interpersonal and communication skills. We report on experience with two specific interventions to foster the teaching and continuous evaluation of these competencies for neurosurgery residents.

MATERIAL AND METHODS

In 2010, the Society of Neurological Surgeons (SNS) organized the first comprehensive Neurosurgery Boot Camp courses, held at six locations throughout the US and designed to assess and teach not only psychomotor skills but also components of all six Accreditation Council for Graduate Medical Education (ACGME) core competencies. These courses are comprised of various educational methodologies, including online material, faculty lectures, clinical scenario and group discussions, manual skills stations, and pre- and post-course assessments. Resident progress in each of the 6 ACGME competencies is now tracked using the neurosurgical Milestones, developed by the ACGME in collaboration with the SNS. In addition, the Milestones drafting group for neurosurgery has formulated a milestone-compatible evaluation system to directly populate Milestone reports. These evaluations utilize formative, summative, and 360-degree evaluations that are considered by a faculty core competency committee in finalizing milestones levels for each resident.

RESULTS

Initial attendance at the 2010 Boot Camp course was 94% of the incoming resident class and in subsequent years, 100%. Pre- and post-course surveys demonstrated a significant and sustained increase in knowledge. The value of these courses has been recognized by the ACGME, which requires Boot Camp or equivalent participation prior to acting with indirect supervision during clinical activities. Neurosurgery was one of 7 early Milestone adopter specialties, beginning use in July, 2013. Early milestone data will establish benchmarks prior to utilization for "high stake" decisions such as promotion, graduation, and termination.

CONCLUSIONS

The full impact of the neurosurgical Boot Camps and Milestones on residency education remains to be measured, although published data from the first years of the Boot Camp Courses demonstrate broad acceptance and early effectiveness. A complementary junior resident course has now been introduced for rising second-year residents. The Milestones compatible evaluation system now provides for multi-source formative and summative evaluation of neurosurgical residents within the new ACGME reporting rubric. Combined with consensus milestone assignments, this system provides new specificity and objectivity to resident evaluations. The correlation of milestone level assignments with other measurements of educational outcome awaits further study.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

The use of simulation in neurosurgical education and training

Object

There is increasing evidence that simulation provides high-quality, time-effective training in an era of resident duty-hour restrictions. Simulation may also permit trainees to acquire key skills in a safe environment, important in a specialty such as neurosurgery, where technical error can result in devastating consequences. The authors systematically reviewed the application of simulation within neurosurgical training and explored the state of the art in simulation within this specialty. To their knowledge this is the first systematic review published on this topic to date.

Methods

The authors searched the Ovid MEDLINE, Embase, and PsycINFO databases and identified 4101 articles; 195 abstracts were screened by 2 authors for inclusion. The authors reviewed data on study population, study design and setting, outcome measures, key findings, and limitations.

Results

Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon's disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18.

Conclusions

The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

OBJECT

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

METHODS

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

RESULTS

A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17).

CONCLUSIONS

The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

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.

Variations in postdelivery infection and thrombosis by hospital teaching status

OBJECTIVE

Using a population-based cohort, we examined hospital-level variation overall and by teaching status in 2 maternal outcomes, postpartum infections, and thrombosis.

STUDY DESIGN

Linked birth certificate and hospital admission records for mother and infant were collected on all deliveries in Pennsylvania and California from 2004 through 2005. A risk adjustment model was created using maternal and fetal comorbidities identified by International Classification of Diseases-9 codes. Hospitals were classified as teaching (TH) or nonteaching hospitals (NTH) based on the presence of obstetrics and gynecology residents. Rates of infections and thrombosis were evaluated overall and by hospital teaching status.

RESULTS

A total of 939,871 patients were evaluated from 402 hospitals (369 NTH and 33 TH). The unadjusted infection and venous thromboembolic events (VTE) rates were higher in TH vs NTH (infection: 2.04% vs 1.07%, P < .001; VTE: 1.04% vs 0.08%, P < .001). There was variation in the rates of these complications across hospitals, with the adjusted observed/expected ratio rates for infection and thrombosis for each hospital, ranging from 0-5.2 and 0-8.6, respectively.

CONCLUSION

There is substantial variation in infection and thrombosis rates among hospitals both overall and by teaching status, suggesting that these 2 outcomes may be useful measures of inpatient obstetric quality.