What’s New in the Patient Safety World

August 2015

Surgical Resident Duty Reform and Postoperative Outcomes

 

 

The major issue regarding work hours in healthcare for both physicians and nurses has always been whether reducing the detrimental effect of fatigue might be offset by reduced continuity of care and increased number of handoffs that would occur after changes in housestaff or nursing hours. No one argues that healthcare worker fatigue is a serious problem (see our many previous columns listed below). But we’ve also discussed in many columns the problems related to handoffs, cross-coverage, and reduced familiarity with patients.

 

In the late 1980’s New York State adopted recommendations of the Bell Commission to limit the number of hours housestaff could work in a week. Subsequently other states and the ACGME have adopted significant restrictions in housestaff hours. The ACGME 80-hour work week restriction was implemented in 2003 and the ACGME in 2011 mandated 16-hour duty maximums for PGY-1 residents. The 2011 changes also mandated residents must have at least 8 hours free between shifts and residents in-house for 24 hours may have up to 4 hours for transfer of care activities and must have at least 14 hours off between shifts.

 

Significantly, most of the restrictions on housestaff work hours were implemented without any formal or systematic measurement of its impact on patient outcomes or for recognition of unintended consequences. So we have always been playing catch-up in assessing the impact of those changes. The evidence of the impact of restricted housestaff hours on patient outcomes and patient safety has been mixed and contradictory (see list of our prior columns below).

 

In our January 2015 What’s New in the Patient Safety World column “More Data on Effect of Resident Workhour Restrictions” we cited a study by Rajaram and colleagues (Rajaram 2014) which found that implementation of the 2011 ACGME duty hour reform was not associated with a change in general surgery patient outcomes or differences in resident examination performance.

 

Now Rajaram and colleagues have looked at the impact of the 2011 ACGME duty hour reform on patient outcomes in several surgical subspecialties (Rajaram 2015). They looked at data from the American College of Surgeons NSQIP database for 5 surgical specialties (neurosurgery, obstetrics/gynecology, orthopedic surgery, urology, and vascular surgery) and used a composite measure of death or serious morbidity within 30-days of surgery for each specialty. They then compared that measure for teaching and non-teaching hospitals for one year prior and two years after the reform. They found there were no significant associations between duty hour reform and the composite outcome of death or serious morbidity in the two years post-reform for any of the 5 surgical specialties.

 

The good news is obviously that there appears to have been no detrimental effect on patient outcomes. The disappointing news is that there was no positive effect on patient outcomes. And there remain numerous questions about the impact on trainee education.

 

Virtually all the studies to date have been observational studies, usually with a before-after format. In our January 2015 What’s New in the Patient Safety World column “More Data on Effect of Resident Workhour Restrictions” we noted that prospective trials of duty hour requirements are being conducted for both surgical (FIRST Trial) and medical (iCOMPARE Trial) training programs.

 

As before, we hope these two trials can help answer some of the questions outstanding regarding multiple aspects of the impact of resident work hour restrictions.

 

 

 

Some of our other columns on housestaff workhour restrictions:

 

December 2008           “IOM Report on Resident Work Hours”

February 26, 2008       “Nightmares: The Hospital at Night”

January 2010               “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 2011               “No Improvement in Patient Safety: Why Not?”

November 2011          “Restricted Housestaff Work Hours and Patient Handoffs”

January 3, 2012           “Unintended Consequences of Restricted Housestaff Hours”

June 2012                    “Surgeon Fatigue”

November 2012          “The Mid-Day Nap”

December 10, 2013     “Better Handoffs, Better Results”

April 22, 2014             “Impact of Resident Workhour Restrictions”

January 2015               “More Data on Effect of Resident Workhour Restrictions”

 

 

Some of our other columns on the role of fatigue in Patient Safety:

 

November 9, 2010      “12-Hour Nursing Shifts and Patient Safety”

April 26, 2011             “Sleeping Air Traffic Controllers: What About Healthcare?”

February 2011             “Update on 12-hour Nursing Shifts”

September 2011          “Shiftwork and Patient Safety

November 2011          “Restricted Housestaff Work Hours and Patient Handoffs”

January 2010               “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           “Unintended Consequences of Restricted Housestaff Hours”

June 2012                    “June 2012 Surgeon Fatigue”

November 2012          “The Mid-Day Nap”

November 13, 2012    “The 12-Hour Nursing Shift: More Downsides”

July 29, 2014               “The 12-Hour Nursing Shift: Debate Continues”

October 2014              “Another Rap on the 12-Hour Nursing Shift”

December 2, 2014       “ANA Position Statement on Nurse Fatigue”

 

 

 

 

References:

 

 

Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance. JAMA 2014; 312(22): 2374-2384

http://jama.jamanetwork.com/article.aspx?articleid=2020372

 

 

Rajaram R, Chkung JW, Cohen ME, et al. Association of the 2011 ACGME Resident Duty Hour Reform with Postoperative Patient Outcomes in Surgical Specialties. J Am Coll Surg 2015; published online July 7, 2015

http://www.journalacs.org/article/S1072-7515%2815%2900428-7/abstract

 

 

The FIRST Trial. Flexibility In duty hour Requirements for Surgical Trainees Trial.

http://www.thefirsttrial.org/Overview/Overview

 

 

iCOMPARE Trial (Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education)

http://www.jhcct.org/icompare/default.asp

 

 

 

 

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