Resident Work Hours Research Articles

Orthopedic Residency: Are Duty Hours Predictive of Performance?

This study examines the relationship between self-recorded resident work hours and Orthopedic In-training Examination (OITE) scores, resident clinical performance, and American Board of Orthopedic Surgery pass rates. The hypothesis of this study is that increasing duty hours would have a positive correlation with clinical and OITE performance. Total duty hours and recorded operating room hours from a single orthopedic residency program were extracted from 2006 to 2012. During the same time span, OITE scores, resident clinical scores from the E-Valuation system, and American Board of Orthopedic Surgery pass rates were collected. The correlation between the variables was assessed using the Pearson correlation coefficient's precision statistic. A large public tertiary academic center in the upper Midwestern United States. A total of 82 orthopedic surgery residents over 7 years. A total of 82 residents were matriculated between 2006 and 2012. The average weekly recorded duty hours were as follows: postgraduate year 2 (PGY2) = 60 hours/week (Standard Deviation (SD) ± 4), PGY3 = 59 hours/week (SD ± 5), PGY4 = 51 hours/week (SD ± 4), PGY5 = 49 hours/week (SD ± 3). There was significant variability in the average number of hours worked among residents (range: 2128-3753h/y) for the full academic year. The OITE scores and the work hours were found to be independent of each other (ρ = 0.017, p = 0.825), and no correlation was found between OITE scores and the resident E-value scores (ρ = 0.071, p = 0.34). Residents spent 36% to 48% of their time in the operating room. Second year residents logging more hours scored higher on faculty evaluation of overall competency (ρ = 0.31, p = 0.035). Faculty assessment of technical skills had a positive correlation with operating room duty hours for PGY5 class (ρ = 0.346, p = 0.025). A large variation in duty hours exists between resident-logged duty hours. No correlation exists between in-training scores and duty hours. There is a positive correlation between senior resident operating room hours and technical skill scores.

Will the year 2016 augur well for better patient safety and health of residents in Korea according to the enactment of the Act for improving the resident training environment and enhancing resident's status?

Will the year 2016 augur well for better patient safety and health of residents in Korea according to the enactment of the Act for improving the resident training environment and enhancing resident's status?

Mid-Level Providers: What Do We Do?

Changes in resident physician work hours have made it increasingly more difficult for physicians to meet the needs of their patients. In many facilities, mid-level providers (MLPs; advanced practice nurses and physician assistants) have become integral members of the medical team in both inpatient and outpatient settings. The purpose of this study was to identify the roles of MLPs in the American Burn Association (ABA) and within burn care teams. There was a 49% return survey response rate. Respondents included 28 (58%) nurse practitioners and 16 (33%) physician assistants. Forty-six percentage of the MLPs had at least 11 years of burn care experience. Forty respondents (87%) worked both inpatient and outpatient settings. Thirty-four (74%) of the providers ran independent clinics. Job responsibilities were in areas of direct patient care, education, and administrative duties. The majority of respondents were members of the ABA, attended annual conferences, and were advanced burn life support instructors. Forty-two (91%) of the MLPs were satisfied with their jobs. In conclusion, MLPs are highly experienced, ABA members and assume direct care of the burn patient.

The Evolving Role of Midwives as Laborists.

This article examines the history and present state of the midwife as laborist. The role of the midwife and obstetrician laborist/hospitalist is rapidly evolving due to the need to improve patient safety and provide direct care due to reduced resident work hours, as well as practice demands experienced by community providers and other factors. Models under development are customized to meet the needs of different communities and hospitals. Midwives are playing a prominent role in many laborist/hospitalist practices as the first-line hospital provider or as part of a team with physicians. Some models incorporate certified nurse-midwives/certified midwives as faculty to residents and medical students. The midwifery laborist/hospitalist practices at Baystate Medical Center in Springfield, Massachusetts, are presented as an example of how midwives are functioning as laborists. Essential components of a successful midwife laborist program include interdisciplinary planning, delineation of problems the model should solve, establishment of program metrics, clear practice guidelines and role definitions, and a plan for sustained funding. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Resident Work Hour Restrictions and Change Management: A Cautionary Tale.

Residents are a significant part of coverage in many hospitals. Resident associations are negotiating work hour limits to prevent fatigue-induced medical errors. Our intensive care unit experienced an unexpected resident shortage and used the opportunity to trial a shift schedule for one month. Post-surveys were sent to nurses, attending physicians and residents to evaluate the effects on staff interactions, patient safety and education quality. The trial was clearly a failure on all fronts. Work hour restrictions are a reality in medical education, and administrators need to start considering alternative staffing models and discussing alternative schedules with their medicine faculty.

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

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

Assessing intern handover processes.

New standards for resident work hours set in 2011 changed the landscape of patient care in teaching hospitals, and resulted in new challenges for US residency training programmes to overcome. One such challenge was a dramatic increase in the number of patient handovers performed by residents. As a result, there is a renewed focus for clinical teachers to develop educational strategies to optimise the patient handover process and improve the quality of patient care and safety. In order to investigate current gaps in resident handovers, we examined the handover processes performed by medicine interns at two academic medical centres in Baltimore, Maryland, USA. We used trained observers to collect data on whether handovers were conducted face to face, with questions asked, in private locations, with written documentation, and without distractions or interruptions. Results were analysed using chi-square tests, and adjusted for clustering at the observer and intern levels. Interns successfully conducted handovers face to face (99.5%), asked questions (85.3%), used private locations (91%), included written handover documentation (95.8%) and did not experience distractions for the majority of the time (87.7%); however, interruptions were pervasive, occurring 41.3 per cent of the time. In order to investigate current gaps in resident handovers, we examined the handover processes performed by medicine interns Interns conducted patient handovers face to face, with questions asked, in private locations, with written documentation and without distractions the majority of the time; however, interruptions during the handover process were common. Exploring gaps at the individual programme level is a critical first step to develop effective teaching strategies to optimise handovers in residency.

Evolving Roles of the Surgeon in the Management of Pediatric Trauma Resuscitation

The traditional paradigm for trauma resuscitations was that a surgeon was always required for leadership. However many changes such as resident work-hour limitations, a shift toward non-operative management, improved trauma triage, and advanced imaging have raised questions about the necessity of a member of the surgical team at all resuscitations. The requirement for surgeon presence is based mostly on opinion rather than data. Our institution has over a decade of experience with pediatric emergency medicine physicians managing minor trauma resuscitations and requiring surgeon presence specifically for the major resuscitations. This has resulted in more appropriate resource allocation without sacrificing patient care in our institution. Other institutions have similarly shifted the focus away from early surgeon involvement while preserving patient safety. We recommend a critical re-evaluation of trauma protocols and systems in requiring surgeon presence as a novel mechanism to improve surgical resource utilization without compromising patient care.

Early impact of the 2011 ACGME duty hour regulations on surgical outcomes

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented additional restrictions on resident work hours. Although the impact of these restrictions on the education of surgical trainees has been examined, the effect on patient safety remains poorly understood. We used national Medicare Claims data for patients undergoing general (n = 1,223,815) and vascular (n = 475,262) surgery procedures in the 3 years preceding the duty hour changes (January, 2009-June, 2011) and the 18 months thereafter (July, 2011-December, 2012). Hospitals were stratified into quintiles by teaching intensity using a resident to bed ratio. We utilized a difference-in-differences analytic technique, using nonteaching hospitals as a control group, to compare risk-adjusted 30-day mortality, serious morbidity, readmission, and failure to rescue (FTR) rates before and after the duty hour changes. After duty hour reform, no changes were seen in the measured outcomes when comparing teaching with nonteaching hospitals. Even when stratifying by teaching intensity, there were no differences. For example, at the highest intensity teaching hospitals (resident/bed ratio of ≥ 0.6), mortality rates before and after the duty hour changes were 4.2% and 4.0%, compared with 4.7% and 4.4% for nonteaching hospitals (relative risk [RR], 0.98; 95% CI, 0.89-1.07). Similarly, serious complication (RR, 1.02; 95% CI, 0.98-1.06), FTR (RR, 0.95; 95% CI, 0.87-1.04), and readmission (odds ratio, 1.00; 95% CI, 0.96-1.03) rates were unchanged. In Medicare beneficiaries undergoing surgery at teaching hospitals, outcomes have not improved since the 2011 ACGME duty hour regulations.

Midwives in medical student and resident education and the development of the medical education caucus toolkit.

Midwives have been involved formally and informally in the training of medical students and residents for many years. Recent reductions in resident work hours, emphasis on collaborative practice, and a focus on midwives as key members of the maternity care model have increased the involvement of midwives in medical education. Midwives work in academic settings as educators to teach the midwifery model of care, collaboration, teamwork, and professionalism to medical students and residents. In 2009, members of the American College of Nurse-Midwives formed the Medical Education Caucus (MECA) to discuss the needs of midwives teaching medical students and residents; the group has held a workshop annually over the last 4years. In 2014, MECA workshop facilitators developed a toolkit to support and formalize the role of midwives involved in medical student and resident education. The MECA toolkit provides a roadmap for midwives beginning involvement and continuing or expanding the role of midwives in medical education. This article describes the history of midwives in medical education, the development and growth of MECA, and the resulting toolkit created to support and formalize the role of midwives as educators in medical student and resident education, as well as common challenges for the midwife in academic medicine. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

An Interactive Web-Based Project to Stimulate Internal Medicine Resident Reading Using Board-Type Questions

Since restricted resident work hours have reduced resident participation in traditional educational activities, we wanted to evaluate e-mail–based education in an internal medicine residency. One internal medicine faculty member sent four clinical case-based questions per week to all internal medicine residents over a 10-month period (132 questions total). The mean percentage of participation on a set of questions was 69% (range, 43% to 97%). The mean percentage of correct answers on all questions for all residents was 70% (range, 15% to 100%). Seventy-three percent of the question sets resulted in an electronic interaction between the residents and the faculty sponsor. Based on an anonymous survey, 96% of the residents found the program useful. The faculty sponsor spent 60 to 150 minutes per week on this activity. We think that this program increased overall reading since it did not replace any traditional activity; further, it provided practice with board-type questions. This approach can supplement the educational curriculum for internal medicine training.

Linda Burnes Bolton, DrPH, RN, FAAN

Dr. Linda Burnes Bolton is an extraordinary nurse leader: visionary, purposeful, committed to mentoring and sponsoring nurses in multiple roles and locations, including advanced practice nurses. An accomplished author, speaker and educator, Linda truly exemplifies "servant leadership." A long-tenured senior nurse executive at Cedars-Sinai Health System, Linda balances local community leadership with her national and international nursing leadership activities. A special view into Linda's success begins with following her "true north" or guiding light, centered on human caring.

Developing the Advanced Practice Recruitment Strategy at an Academic Medical Center: The APRN Pipeline

The Institute of Medicine's (IOM) recommendation to remove barriers to practice and enable advanced practice registered nurses (APRNs) and registered nurses (RNs) to practice to the full extent of their education and training 1 expanded the use of advanced practice nurses in the country. The more restrictive Accreditation Council for Graduate Medical Education (ACGME) and Residency Review Committee (RRC) requirements on residency training and work hours increased the hiring of APRNs to fill the void created by a reduction in GME trainees. 2 Finally, the Affordable Care Act created additional demand for more providers to meet the needs of the newly insured population, particularly in primary care. 3

Assessing the Utility of ICU Readmissions as a Quality Metric: An Analysis of Changes Mediated by Residency Work-Hour Reforms

ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed after 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes. We used a difference-in-differences approach using Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks). Piecewise regression models estimated changes in outcomes immediately before and after reform in 274,491 critically ill medical and surgical patients in 151 community and academic US ICUs. Outcome measures included ICU readmission, ICU mortality, and in-hospital post-ICU-discharge mortality. In ICUs with residents, ICU readmissions increased before reform (OR, 1.5; 95% CI, 1.22-1.84; P < .01), and decreased after (OR, 0.85; 95% CI, 0.73-0.98; P = .03). This abrupt decline in ICU readmissions after reform differed significantly from an increase in readmissions observed in ICUs without residents at this time (difference-in-differences P < .01). No comparable changes in mortality were observed between ICUs with vs without residents. The changes in ICU readmission rates after reform, without corresponding changes in mortality, suggest that ICU readmissions are not causally related to other untoward patient outcomes. Instead, ICU readmission rates likely reflect operational aspects of care that are not patient-centered, making them less useful indicators of ICU quality.

Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means (P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation (P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation (P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Redefining Professionalism in an Era of Residency Work-Hour Limitations

Case Jake arrived home from the hospital and said to his wife, Emma, “How should I deal with this?” He waved several sheets of paper in the air before letting them drop on the desk where Emma was working. “It’s a 360-degree performance evaluation of interns, so they’re asking us to evaluate our peers.” “Glad we don’t have that in surgery.” Emma said. “You medicine docs are so….”

2014 winning essay: redefining professionalism in an era of residency work-hour limitations.

2014 winning essay: redefining professionalism in an era of residency work-hour limitations.

Factors influencing resident performance of invasive bedside procedures

In the United States, with changes to resident work hour rules and internal medicine residency procedure requirements, residents are no longer required to perform specific procedures as part of their training. Despite this change, residents continue to encounter patients needing procedures. No study has yet to quantify the amount of procedures residents encounter with the number performed. In our study, we explored internal medicine residents' decision making regarding the performance and referral of invasive bedside procedures, as well as objectively reviewed residents' procedure performance patterns.

Provider Based Outcomes on an Allogeneic Transplant Service

Introduction:Allogeneic stem cell transplantation (ASCT) is a potentially curative, although highly morbid procedure for some patients with hematologic malignancies. Care of patients undergoing ASCT is highly specialized, and often complicated. Traditionally, the majority of transplants occur at tertiary academic centers where housestaff (medical residents) provide daily care. However, with new limitations on resident work-hours, alternative models of team based care replacing residents with Advanced Practice Providers (nurse practitioners/physician assistants) have been utilized. In this study we compared outcomes on a housestaff (HS) based allogeneic transplant service to outcomes on an Advanced Practice Provider (APP) based service.Methods:A retrospective chart review of ASCT patients admitted to the Hospital of the University of Pennsylvania was performed. Prior to July 2012, all ASCT patients were admitted to a HS service (staffed by residents, a fellow, and an attending). Starting July 2012, all new ASCT patients were admitted to a newly developed APP service (staffed by 2 APPs, an attending, and overnight moonlighters). We evaluated 86 patients admitted to the HS service from May 2011 to May 2012 and 81 patients admitted to the APP service from Oct 2012 to Oct 2013. Patients from June 2012 to September 2012 were excluded due to transition and cross-over during the initial months of the new service. A subset of 27 overflow ASCT patients admitted to the housestaff service from Oct 2012 to Oct 2013 was studied as part of a secondary analysis. For our primary analysis, we compared patient, provider, and cost outcomes pre and post July 2012 on the HS and APP services. Patient outcomes included 100 day relapse free and overall survival rates, length of stay (LOS), 14 & 30 day re-admission rates, in-hospital death rate, ICU transfers, and infectious complications such as pneumonia (PNA), urinary tract infections, bacteremia, and C. Diff colitis. Descriptive and comparative analyses were performed using a t-test for continuous variables, chi-squared and Fisher’s exact test for categorical variables, and a Wilcoxon rank-sum test for ordinal variables.Results:Baseline characteristics among patients on the APP and HS services revealed no statistically significant differences in mean age, gender, indication for transplant, donor type (allo-sib vs MUD vs cord graft), or conditioning regimen (myeloablative vs reduced intensity). More patients were transplanted with active disease on the APP service (41% vs 27%, p=0.06), but the difference was not statistically significant. ECOG performance status and a hematopoietic cell transplantation-specific comorbidity index score were also not significantly different between the groups. The rate of PNA was significantly less on the APP service (15% vs 28%, p=0.04) while other infectious complications were similar in both groups. There were several important findings that did not reach statistical significance, including less in-hospital death on the APP service (4% vs 10%, p=0.09), a decrease in ICU transfers on the APP service (8.6% vs 18.6%, p=0.06) and a three day absolute difference in the mean LOS favoring a shorter hospitalization on the APP service (p=0.12) with no difference in 14 or 30 day re-admission rates. 100 day survival rates and relapse free survival rates were similar in both groups with slightly less relapse in the APP group (p=0.08). Lastly, hospital charges and total costs of the hospitalization were not significantly different although there was an increase in testing on the HS service in terms of number of radiological films (5 vs 8, p=0.05) and number of blood cultures ordered (4 vs 7, p=0.03).Conclusions:With increasing demands on the physician work force, alternative models of care are increasingly employed. In our study, the development of a specialized inpatient APP allogeneic transplant service suggests that there may be a decreased length of stay, fewer ICU transfers, and fewer in-hospital deaths. There were potential cost-saving benefits due to decreased utilization of laboratory and radiological testing. In conclusion, APPs are a safe and feasible alternative care approach to the traditional HS model for patients undergoing ASCT. Additional studies need to be performed to ensure that both the quality and cost of patient care are maximized as new care models are developed. DisclosuresNo relevant conflicts of interest to declare.

Effects of the reduction of surgical residents' work hours and implications for surgical residency programs: a narrative review.

BackgroundThe widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.MethodsWe searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.ResultsWe retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.ConclusionsFurther studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.