The 80Hour Resident Workweek Does Not Adversely Affect Patient Outcomes or Resident Education

1
The 80-Hour Resident Workweek Does Not
Adversely Affect Patient Outcomes or Resident
Education

• Christian de Virgilio MD, Arezou Yaghoubian BS,
• Roger J. Lewis MD, Bruce E. Stabile MD and
• Brant A. Putnam MD

2
Pros and Cons of Duty Hour Reforms

• Pros
• Better rested resident at work
• Fewer medical errors
• Improved resident quality of life at home

• Cons
• Less competent surgeon
• Decreased operative experience
• Disruption in continuity of care
• Decreased patient exposure
• Poorer performance on ABSITE and ABS exams
• Deleterious effects on patient outcome
• Frequent shift changes
• Breakdown in communication
• Increased need for cross coverage

3
Sleep Deprivation and Medical Error

• Survey of anesthesiologists
• 61 made fatigue-related errors (Gravenstein et
  al, Anesthes)
• Surgeons on call gt 24 hours
• 30 more surgical time required (Goldman et al, J
  Surg Res)
• Laparoscopic studies
• 20 more errors and 14 longer to complete tasks
• (Taffinder et al, Lancet)

4
Lessons From the New York Experience

• Resident Survey
• Quality of life (QOL)
• 64 more rested
• 66 improved QOL outside hospital
• 42 improved QOL at work
• Education
• 35 impaired surgical training
• 50 reduction in operations
• 51 missed learning opportunities
• Patient care
• 35 harmed quality of patient care
• 60 negative impact on continuity of care
• Whang et al Ann Surg 2003

5
Purpose of Study

• To evaluate the effects of the restricted hours
  on
• Patient outcome
• Morbidity and mortality on the trauma service
• Surgical resident education
• Operative volume
• ABSITE scores
• ABS Qualifying and Certifying passage rates
• Institutional cost incurred to comply with work
  hours

6
Harbor-UCLA General Surgery Program

• University affiliate, Los Angeles County Hospital
• 2nd busiest Level I trauma center
• Six-year program
• 4 categorical/year, 8 NDP, 6 DP residents
• One research year
• 5 year accreditation
• Full time academic faculty

7
Changes in the Residency Program

• Anonymous resident survey, April 2002
• Eliminated redundancy of in-house call
• Reduced in-house call for outside rotations
• Added/eliminated rotations to optimize operative
  volume
• Medical personnel
• Increase in PGY1 transitional year residents on
  surgery
• Increase in nurse practitioners
• November 2004, temporary approval to increase
  categorical complement from 4?5 residents/year
• Restructuring of the trauma service

8
Changes in Resident Education

• Weekly junior resident noon conference
• Weekly reading assignments followed by weekly
  examinations in an ABSITE format
• PGY 1 and 2 residents required to present at
  grand rounds
• Yearly operative volume target goals for each PGY
  level
• Surgical Jeopardy

9
Methods

• Compared 2 time periods
• Period 1 (5 academic years 1998 to 2002)
• Period 2 (2 academic years 2003 and 2004)
• Effects on resident education
• Operative volume
• ACGME Oplog
• Chief year and overall total major cases
• Mean ABSITE percentile scores
• 1st time pass rates on American Board of Surgery
  qualifying and certifying exams

10
Methods

• Effect on trauma patient outcome
• TEMIS, prospective registry (retrospective
  review)
• Variables
• ISS
• Mechanism of injury
• Volume
• Main outcome measures
• Complications
• Mortality

11
Methods

• Resident work hours
• Mean number of call nights per resident
• Cost of the 80-hour workweek
• Additional manpower
• Web-based duty hour tracking software

12
Statistical Analysis

• Trauma data transferred from registry into Excel
  and translated into SAS
• Descriptive statistics calculated for all
  variables
• Numerical variables
• Non-parametric Wilcoxon rank sum test
• Categorical or nominal variables
• Chi square test or Fishers exact test
• p lt 0.05 statistically significant

13
Results

• Mean Call Schedule

2000-2002 Mean Q 4.8
2003-2004 Mean Q 6.4
14
Chief Resident Case Volume
15
Graduating Resident Total Major Case Volume
16
Graduating Resident Total Major Case
Volume,Periods 1 2
Plt0.0001
17
Mean ABSITE Percentiles for All Residents
Weekly ABSITE review instituted
18
Mean ABSITE Percentiles, Periods 1 2
19
1st Time Pass Rates on ABS Exams
20
Trauma Patient Characteristics
21
Patient Outcomes
22
Cost of the 80-Hour Workweek

• Current Costs ?
  Projected Costs
• 300,000 5 Nurse practitioners
  300,000 5 Nurse practitioners
• 55,000 1.5 Transitional residents
  55,000 1.5 Transitional residents
• 4,000 Duty hour software
  4,000 Duty hour software
• 
  270,000 6 Categorical
  residents
• __________________________________________________
  ____________________
• 359,000 629,000

23
Duty Hours and Resident Education

• Ferguson et al (Curr Surg)
• No change in mean operative volume
• Barden et al (J Am Coll Surg)
• Improved quality of life
• Improved ABSITE for junior but not senior
  residents
• Increased total number of cases
• Perceived negative impact on continuity of
  patient care
• Hassett et al (Ann Surg)
• Improved ABS qualifying exam
• No change in mean operative volume

24
Duty Hours Restrictions and Patient Outcomes

• Mycyk et al (Am J Syst Health Pharm)
• No significant differences in adverse drug events
  
• Schenarts et al (Am J Surg)
• No effect on length of hospital or ICU stay,
  ventilator days, or mortality/complication rate
  at a Level I trauma center
• Kaafarani et al (J Surg Res)
• Mortality and post-operative outcomes not
  affected
• Significant decrease in deep surgical site
  infections
• Higher rate of acute renal failure

25
Summary of Findings

• Resident work hours
• In house call decreased from every 4th to every
  6th night
• Resident education
• Mean ABSITE percentiles trended upwards
• Mean total operative case volume increased
• Mean chief year case volume trended upwards
• 1st time ABS qualifying and certifying exam pass
  rates unchanged

• Patient outcome
• Morbidity and mortality rates on trauma service
  unchanged
• Significant decreases in the following
  complications
• Intra-abdominal abscess
• Pneumonia
• DIC

26
Study Limitations

• Post-work hour data encompasses short time period
• Future studies needed to determine long term
  effects of duty hour limitations on resident
  training and beyond
• Data only represents one training program
• Larger scale studies are needed to study the
  effects of work hour restrictions across the U.S.

27
Conclusion

• General surgery residency program can comply with
  duty hour standards without compromising patient
  care, resident education, or resident operative
  experience
• To achieve this goal, modifications of resident
  surgery educational curriculum and rotation
  schedule necessary
• Resident work hour compliance can be undertaken
  with reasonable institutional expenditures