Resident Duty Hours Research Articles

Expeditious emergency room referral pathway improves patient access to otolaryngology care

ObjectivesHistorically at a multi‐hospital residency program, there was an unexpected number of non‐urgent consults from the county hospital emergency room (ER) that caused residents to make more trips between hospitals and come closer to violating duty hours. Moreover, there was also a poor follow‐up rate for these patients. An alternate pathway to redirect such consults to the Otorhinolaryngology–Head and Neck Surgery (ORL–HNS) clinic, staffed by an attending physician, was devised. This study illustrates how an undemanding process change can improve access to care, and resident duty hours and satisfaction.Study DesignQuality Improvement StudyMethodsThe average rate of no‐show appointments and overall number of patients referred from the county hospital ER; a survey of impact on resident workload; and an average number of on‐call resident trips to county hospital were compared in the 12 months before and after implementation of an expedited ER referral pathway.ResultsThe overall number of patients referred to clinic from ER increased by 35% (123 to 166 patients). The average number of completed visits for patients referred to the ORL‐HNS clinic from the ER increased by 29% (91 to 117 patients). There was no statistically significant change in the no‐show rate of said patients. The average number of overnight resident trips to the county hospital, frequency of resident unpreparedness for routine clinical duty and need to alter schedule to avoid duty hour violations all decreased, while resident satisfaction increased.ConclusionsAn undemanding process change in a safety‐net, publicly‐funded, county hospital setting can decrease resident workload and improve satisfaction while possibly improving patient access to specialty clinic care and follow‐up rates for patients.Level of Evidenceclinical outcomes, level IV

Perceptions of the 2011 ACGME duty hour requirements among residents in all core programs at a large academic medical center

BackgroundThe Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center.MethodsThe authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other.ResultsIn total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%).ConclusionsA majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.

An Appeal for Evidence-Based Resident Duty Hours Reform

An Appeal for Evidence-Based Resident Duty Hours Reform

Estimation of Population Average Treatment Effects in the FIRST Trial: Application of a Propensity Score-Based Stratification Approach.

To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial ("FIRST Trial"). Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014-2015). The FIRST Trial was a cluster-randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent-to-treat framework. Propensity score-based poststratification was used to estimate PATE. This study was a secondary analysis of previously collected data. Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. Propensity score-based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.

Subjective and Objective Measurement of Neonatal Nurse Practitioner Workload.

Neonatal nurse practitioner (NNP) workload is not well studied, and metrics specific to NNP practice are lacking. Factors such as changes in resident duty hours, increasing neonatal intensive care unit admissions, and a shortage of NNPs contribute to NNP workload. Increased workload has been shown to be detrimental to providers and can affect quality of care. This study quantified NNP workload using a subjective workload metric, the NASA Task Load Index, and a newly developed objective workload metric specific to NNP practice. The NNP group at a level IV academic medical center was studied. The sample included 22 NNPs and 47 workload experiences. A comparison of scores from the NASA Task Load Index and objective workload metric showed a moderate correlation (r = 0.503). Mental demand workload scores had the highest contribution to workload. Feelings of frustration also contributed to workload. The NASA Task Load Index can be utilized to measure the workload of NNPs. The objective workload metric has potential to quantify NNP workload pending further validation studies and is a simple, straightforward tool. Additional research is needed regarding NNP workload and methods to quantify workload. Larger studies are needed to validate the objective workload metric.

Perspective of Residency Program Directors on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Perspective of Residency Program Directors on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Perspective of the FIRST Trial Investigators on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Perspective of the FIRST Trial Investigators on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Perspective of Surgical Resident Trainees on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Perspective of Surgical Resident Trainees on Accreditation Council for Graduate Medical Education Changes in Resident Work Environment and Duty Hours

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty

The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool. Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori. A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service. Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.

Association of Resident Duty Hour Reform and Neonatal Outcomes of Very Preterm Infants.

Objective To assess the association of the 2011 Quebec provincial resident duty hour reform, which reduced the maximum consecutive hours worked by all residents from 24 to 16 hours, with neonatal outcomes. Study Design Retrospective observational study of 4,271 infants born between 23 and 32 weeks, admitted at five Quebec neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network (CNN) between 2008 and 2015 was conducted. Adjusted odds ratios (AORs) were calculated to compare mortality and the composite outcome of mortality or major morbidity before and after the implementation of the duty hour reform. Results The mortality rate was 8.4% (218/2,598) before the resident duty hour reform and 8.6% (182/2,123) after the reform (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.83–1.26). The composite outcome rate was 32% (830/2,598) before the duty hour reform and 29% (615/2,123) after the reform (OR = 0.87, 95% CI = 0.77–0.98). In the adjusted analyses, the resident call-hour reform was not associated with a significant change in mortality (AOR = 1.17, 95% CI = 0.91–1.50) or composite outcome (AOR = 0.87, 95% CI = 0.74–1.03). Conclusion Reducing residents' duty hours from 24 to 16 hours in Quebec was not associated with a difference in mortality or the composite outcome of very preterm infants.

Physician extenders on surgical services: asystematic review.

With the introduction of resident duty hour restrictions and the resulting in-house trainee shortages, a long-term solution to ensure safe and efficient patient care is needed. One solution is the integration of nurse practitioners (NPs) and physician assistants (PAs) in a variety of health care settings. We sought to examine the use of NPs and PAs on surgical/trauma services and their effect on patient outcomes and resident workload. We performed a systematic review of EMBASE, Medline, CINAHL, and the Cochrane Central Register of Controlled Trials. We included studies (all designs) examining the use of NPs and PAs on adult surgical and trauma services that reported the following outcomes: complications, length of stay, readmission rates, patient satisfaction and perceived quality of care, resident workload, resident work hours, resident sleep hours, resident satisfaction, resident perceived quality of care, other health care worker satisfaction and perceived quality of care, and economic impact assessments. We excluded studies assessing nonsurgical/trauma services or pediatrics and review articles. Twenty-nine articles met the inclusion criteria. With the addition of NPs and PAs, patient length of stay decreased, and morbidity and mortality were unchanged. In addition, resident workload decreased, sleep time increased, and operating time improved. Patient and health care worker satisfaction rates were high. Several studies reported cost savings after the addition of NPs/PAs. The addition of NPs and PAs to surgical/trauma services appears to be a safe, cost-effective method to manage some of the challenges arising because of resident duty hour restrictions. More high-quality research is needed to confirm these findings and to further assess the economic impact of adding NPs and PAs to the surgical team.

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

ImportanceFree flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor.ObjectivesTo characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome.Design, Setting, and ParticipantsThis multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices.Main Outcomes and MeasuresTechnique, frequency, and personnel for flap monitoring; flap complications; and flap success.ResultsOverall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different.Conclusions and RelevanceAcademic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden.

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study [23OP

INTRODUCTION: The Obstetrics program at the University of Toronto recently adopted a “night float” system, whereby residents work for a restricted number of hours overnight, but for four consecutive nights. The objective of this study was to determine if there has been a change in obstetrical patient outcomes following the introduction of restricted resident work hours. METHODS: We performed a population-based, retrospective cohort study using linked healthcare administrative databases in the province of Ontario, Canada. We included all obstetrical patients who underwent a delivery between July 2011 and June 2015 (two years prior to and after the implementation of resident duty hour restrictions), at three academic hospitals in Toronto, Canada. The primary outcome was a composite index of numerous maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions and surgical/obstetrical complications. Secondary outcomes included assessment of each of the components of the primary outcome examined separately. A generalized estimating equation model, clustered by institution, was utilized to assess for a difference post-intervention. RESULTS: The pre-intervention cohort consisted of 6,763 deliveries, and the post-intervention cohort 5,548 deliveries. There were no differences in baseline patient demographics between groups. After the implementation of the restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.2298, P=.0016) and transfusion/postpartum hemorrhage (OR 1.2629, P=.0006) was found. CONCLUSION: Since the implementation of resident duty hour restrictions with the addition of consecutive night shifts, there was an increased incidence of surgical/obstetrical complications and transfusion/postpartum hemorrhage.

Resident Duty Hours and American Board of Surgery In-Training Examination Performance

Resident Duty Hours and American Board of Surgery In-Training Examination Performance

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

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. This analysis evaluated post-work hour reform effects on HAC incidence for US hospital inpatients, using the National Inpatient Sample. 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. 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). Post-2003 era patients were associated with 10% increased likelihood of HAC, with effects noted primarily at teaching hospitals.

The July Effect on Maternal Peripartum Complications before and after Resident Duty Hour Reform: A Population-Based Retrospective Cohort Study.

Objective To compare maternal birth complications early versus late in the academic year and to evaluate the impact of resident work hour limitation on the "July effect." Study Design We conducted a retrospective, population-based cohort study of 628,414 singleton births in Washington State from 1987 to 2012 measuring the adjusted risk of maternal peripartum complications early (July/August) versus late (April/May) in the academic year. To control for seasonal outcome variation unrelated to trainees' involvement in care as well as long-term trends in maternal complications unrelated to variation in trainees' effect on outcomes across the academic year, we employed difference-in-differences methods contrasting outcomes at teaching to nonteaching hospitals for deliveries before and after restriction of resident work hours in July 2003. Results Prior to resident work hour limitation in July 2003, women delivering early in the academic year at teaching hospitals suffered more complications (relative risk [RR] 1.05; 95% confidence interval [CI]: 1.00-1.09; p = 0.03). After July 2003, complication risk did not vary significantly across the academic year except at teaching-intensive hospitals, where July/August deliveries experienced fewer complications (RR: 0.95; 95% CI: 0.92-0.98; p = 0.001). Conclusion Women delivering at teaching hospitals early in the academic year suffered a modest but significant increase in complications before but not after resident work hour reform.

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

ImportanceGraduate 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.ObjectiveTo 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 ParticipantsRetrospective 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 MeasuresProcedure-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.ResultsTotal 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 RelevanceWhile 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.

The Nasal Fracture Algorithm: A Case for Protocol‐Driven Management to Optimize Care and Resident Work Hours

Since the initiation of resident duty hour restrictions, significant controversy has arisen regarding its impact on surgical resident training. We reviewed a singular facet of the otolaryngology residency experience, nasal bone fracture management, to identify if treatment standardization would improve care and efficiency. For 1 year, otolaryngology consults for isolated nasal fractures were analyzed to assess consultation trends, rate of intervention, and resident work hour utilization. Following a review of the literature, an evidence-based algorithm for management of nasal fractures was developed. Analysis revealed a potential improvement in intervention rate from 20% to 100% with utilization of the algorithm, with an 84% decrease in overall emergency room and inpatient consultations. Sixty-three hours of otherwise lost resident time would be gained. In the setting of Accreditation for Graduate Medical Education duty hour restrictions, implementation of protocol-driven management may result in a decrease in work hours and serve as a model for more efficient otolaryngology care.

Restrictions on surgical resident shift length does not impact type of medical errors

BackgroundIn 2011, resident duty hours were restricted in an attempt to improve patient safety and resident education. With the goal of reducing fatigue, shorter shift length leads to more patient handoffs, raising concerns about adverse effects on patient safety. This study seeks to determine whether differences in duty-hour restrictions influence types of errors made by residents. Materials and methodsThis is a nested retrospective cohort study at a surgery department in an academic medical center. During 2013-14, standard 2011 duty hours were in place for residents. In 2014-15, duty-hour restrictions at the study site were relaxed (“flexible”) with no restrictions on shift length. We reviewed all morbidity and mortality submissions from July 1, 2013-June 30, 2015 and compared differences in types of errors between these periods. ResultsA total of 383 patients experienced adverse events, including 59 deaths (15.4%). Comparing standard versus flexible periods, there was no difference in mortality (15.7% versus 12.6%, P = 0.479) or complication rates (2.6% versus 2.5%, P = 0.696). There was no difference in types of errors between periods (P = 0.050-0.808). The most number of errors were due to cognitive failures (229, 59.6%), whereas the fewest number of errors were due to team failure (127, 33.2%). By subset, technical errors resulted in the highest number of errors (169, 44.1%). There were no differences between types of errors of cases that were nonelective, at night, or involving residents. ConclusionsAmong adverse events reported in this departmental surgical morbidity and mortality, there were no differences in types of errors when resident duty hours were less restrictive.

Comparison of Patient Outcome Measures between a Traditional Teaching Hospitalist Service and a Non-Teaching Hospitalist Service at an Academic Children's Hospital.

Background and objectivesInpatient pediatric care is increasingly provided by pediatric hospitalists. This, in addition to changes in resident duty hour restrictions, has led to the creation of new models of care for inpatient pediatric patients. The objective of this study was to compare traditional outcome measures between a pediatric hospitalist-only service and a more traditional academic service in which care was provided by pediatric hospitalists, residents, and medical students. Attending physicians on the hospitalist-only service had an average of 1.7 years of post-residency experience compared to an average 16 years of experience for those working on the traditional academic service.MethodsThis retrospective cohort study (hospitalist-only v. teaching service) used electronic medical records data of patients (n=1,059) admitted to a quaternary care, academic, children’s hospital in Pittsburgh Pennsylvania with diagnoses of bronchiolitis, viral syndrome, and gastroenteritis from July 2011 to June 2014. Primary outcome measures included length of stay, hospital costs, and readmission rates.ResultsPatients with a diagnosis of bronchiolitis admitted to the hospitalist-only service had a significantly higher severity-of-illness-score than those admitted to the teaching service. A decreased length of stay and lower hospital costs were seen for patients admitted to the hospitalist-only service; however, these differences did not reach a level of statistical significance.ConclusionThere were no statistically significant differences in the outcome measures of patients with common pediatric illnesses admitted to a hospitalist-only versus a teaching hospitalist service. The model of a hospitalist-only service staffed by recent residency graduates may provide an efficient and effective model of care as patients admitted to this service had similar outcome measures to those patients cared for by more-experienced attending physicians.