What’s New in the Patient Safety World

January 2015

More Data on Effect of

Resident Workhour Restrictions

 

 

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.

 

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 1980’s 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:

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).

 

Let’s 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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