Does Resident Call affect the patient outcomes of lengthof stay, transfer to ICU, or inpatient death

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Does Resident Call affect the patient outcomes of
length-of -stay, transfer to ICU, or inpatient
death for the diagnosis of pneumonia?

• A Pilot Study
• Alan Kelton, M.D.

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AKA The DRCAFOLOSTICUIDDP Study
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Resident call

• R2 for Wards at UMC
• Traditional Type Year 1999-2000 (Year 1)
• Mixed Year 2000-2001
• Random Night Coverage (Year 2)
• Dedicated Night Float (Year 3)
• Intern call Unchanged During the Study Years

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Effects of Call System

• More Laboratory Tests, Trend toward Increased LOS
  with CC admissions
• 44 v 32 Laboratory Tests (p 0.01)
• 8 v 6 days (p 0.06)
• VAMC Minneapolis
• Lofgren, J Gen Intern Med 1990

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Effects of Call System

• Night Float, VAMC Minneapolis
• Decreased LOS (10.9 v 9.3) p lt0.01
• Fewer Lab Tests (24 v 19) p lt0.01
• Fewer Rx Errors (16.9 v 12) p 0.02
• Gottlieb, Arch Int Med 1991

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Effects on Work Hour Limitations

• Resident Night Float, Intern Cross Cover at New
  York Hospital
• No significant differences in outcomes for
  inpatient mortality, transfer to ICU, discharge
  disposition or LOS
• Significant differences in electrolyte
  abnormalities, test delays.
• Laine, JAMA 1993

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Call System at UMC

• 2nd Year Senior Residents Wards
• Natural Evolution over last four years
• Traditional 24 hour call 1999-2000
• Mixed call 2000-2001
• Random Night Coverage 2001-2002
• Night Float 2002-2003
• Intern Split Call Throughout

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The Pilot Study

• Compare only A and B Call for three distinct
  call systems
• Year 1 (1999-2000)
• Year 2 (2001-2002)
• Year 3 (2002-2003)
• Avoid July Phenomenon
• December and January
• Common Diagnosis (Diagnoses)

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Common Diagnoses

• December 02
• Single LB
• Pneumonia 486
• Chest Pain
• Delivery with Lac
• C-Section Delivery
• CHF
• Normal Delivery
• Acute Pancreatitis
• VBAC
• Asthma

• January 03
• Single LB
• Pneumonia 486
• Chest Pain
• C-Section
• CHF
• Del with Lac
• VBAC
• Stroke
• Del with 2nd degree
• Acute Bronchiolitis

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Electronic Chart Review

• 140 patients identified with Pneumonia, Asthma
• 87 Adult Patients with Pneumonia
• Reviewed 9 charts by HP or D/C Summary
• All with death or ICU days
• 5 Eliminated due to Initial ICU admission or
  Family Practice admission

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Patients
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Length of Stay
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LOS Significance

• Kruskal-Wallis Test
• 0.496
• No Significance

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Death
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Transfer ICU
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Power CalculationLength of Stay

• To detect a Difference 1 day, Power 80
• 172 Subjects total
• An analysis of one year should provide adequate
  numbers of subjects

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Power Calculation Death or Transfer to ICU

• To detect a difference between three groups
• 3,180 Subjects for a Power of 80
• Multiple diagnoses would be required to study the
  call systems

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Conclusion

• This Pilot Study demonstrates no difference
  between call systems for the diagnosis of
  pneumonia in a limited period of comparison.
• This study establishes a number of 172 subjects
  as the minimum required to detect a one day
  difference with a power of 80.

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Refernces

• Lofgren RP, D Gottlieb, RA Williams, EC Rich.
  Post-call transfer of resident responsibility
  its effect on patient care. J Gen Intern Med
  19905501-505
• Laine C, L Goldman, JR Soukup, JG Hayes. The
  impact of a regulation restricting medical house
  staff working hours on the quality of patient
  care. JAMA. 1993269374-378
• Gottlieb DJ, C. M. Parenti, CA Peterson, RP
  Lofgren. Effect of a change in house staff work
  schedule on resource utilization and patient
  care. Arch Intern Med. 19911512065-2070
• Rich EC, SD Hillson, B Dowd, N Morris. Specialy
  differences in the July phenomenon for twin
  cities teaching hospitals. Med Care 1993
  3173-83.

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Faculty And Assistance

• Faculty Advisor Michael Peterson, M.D.
• Statistics And Design Ronna Mallios, UCSFresno,
  Office of Sponsored Projects
• Subject Development Paul Goebel, M.D. Tom
  Baudendistel, M.D. Ivy Darden, M.D.