Whats New in the Patient Safety World
January 2015
More
Data on Effect of
Resident
Workhour Restrictions
In the late 1980s
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.
These
recommendations have been based on the well-known impact of fatigue on
healthcare workers (see list of our prior columns below). But we suspected even
back in the 1980s that benefits from reduced housestaff
fatigue might well be offset by detrimental effects of increased cross-coverage
and an increased number of handoffs that would occur after the change in housestaff hours. 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.
The subsequent
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). And any study looking at the impact of
restricted work hours needs to look at patient outcomes, adverse events, housestaff wellness and well-being, and how well we educate
and prepare our residents for their future practice in healthcare.
Add to those prior studies several new studies. Two such studies recently appeared in JAMA. In the first (Patel 2014) the authors found no significant differences among Medicare beneficiaries in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.
The second study (Rajaram 2014)
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.
In addition, another systematic review (Harris 2014) found some support for improved resident quality of life and improved resident sleep and less fatigue but a perceived negative impact on surgical operative and technical skill and conflicting evidence on the topics of resident education, patient outcomes, and variable attitudes toward the work-hour changes. The authors again noted there is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours.
Virtually all the
studies to date have been observational studies, usually with a before-after
format. Most of us have doubted that a true randomized controlled trial could
ever be done regarding the impact of workhour
restrictions. But, in fact, two such trials are planned, with support from the
ACGME. The FIRST Trial
will be a prospective trial to examine how increasing flexibility of surgical
resident duty hour requirements affects patient care, surgical outcomes, and
resident perceptions. Hospitals will be randomized to either an intervention
group with flexibility of duty hour restrictions (elimination of many duty hour
requirements) or a control group with continued adherence to current
requirements. Those hospitals randomized to the intervention arm will be
granted a waiver from current duty hour requirements by the ACGME.
The iCOMPARE trial is a one-year cluster randomized trial that will assign participating ACGME-accredited Internal Medicine training programs to one of two duty-hour regimens:
- Current regimen; or
- Flexible regimen (up to 80 hours per week, 1 day off in 7, night
call no more than one in three, all averaged over four weeks)
Outcomes include
measures of patient safety and trainee education. The ACGME will provide duty
hour waivers to all participating programs from July 2015 through at least June
2019 (or until action is taken on duty hour policy).
Lets 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
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:
Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME Resident Duty Hour Reforms With Mortality and Readmissions Among Hospitalized Medicare Patients. JAMA 2014; 312(22): 2364-2373
http://jama.jamanetwork.com/article.aspx?articleid=2020371
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
Harris JD, Staheli G, LeClere L, et al. What Effects Have Resident Work-hour Changes Had on Education, Quality of Life, and Safety? A Systematic Review. Clinical Orthopaedics and Related Research 2014; October 2014 Published online: 01 Oct 2014
http://link.springer.com/article/10.1007%2Fs11999-014-3968-0
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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