Whats 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 weve also discussed in many columns the
problems related to handoffs, cross-coverage, and reduced familiarity with
patients.
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. 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 Whats
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 Whats
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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