Wednesday, June 08, 2005

Does the 80-hour Workweek Improve Safety?????
From the Annals of Surgery: Resident Work Hour Limits and Patient Safety
Objective: This study evaluates the effect of resident physician work hour limits on surgical patient safety.

Background: Resident work hour limits have been enforced in New York State since 1998 and nationwide from 2003. A primary assumption of these limits is that these changes will improve patient safety. We examined effects of this policy in New York on standardized surgical Patient Safety Indicators (PSIs).

Methods: An interrupted time series analysis was performed using 1995 to 2001 Nationwide Inpatient Sample data. The intervention studied was resident work hour limit enforcement in New York teaching hospitals. PSIs included rates of accidental puncture or laceration (APL), postoperative pulmonary embolus or deep venous thrombosis (PEDVT), foreign body left during procedure (FB), iatrogenic pneumothorax (PTX), and postoperative wound dehiscence (WD). PSI trends were compared pre- versus postintervention in New York teaching hospitals and in 2 control groups: New York nonteaching hospitals and California teaching hospitals.

Results: A mean of 2.6 million New York discharges per year were analyzed with cumulative events of 33,756 (APL), 36,970 (PEDVT), 1,447 (FB), 10,727 (PTX), and 2,520 (WD). Increased rates over time (expressed per 1000 discharges each quarter) were observed in both APL (0.15, 95% confidence interval, 0.09-0.20, P<0.05)

Three sets of hospitals were studied, New York teaching hospitals, New York non-teaching hospitals ,and California teaching hospitals. This was done to provide both geographic proximity during the time in question as well as teaching hospitals not affected by workhour limits. This study does a better job of telling us "this is the way it is" than "why is it this way"?
Our results suggest that unintended consequences of resident work hour limits may have occurred in teaching hospitals only. Possibly, more technical errors during procedures (APL) are occurring as surgical trainees have fewer hours with which to become technically proficient during their training. In addition, the increased number of shifts made necessary by shorter work schedules may increase the number of informational exchanges by caregivers; this scenario might lead to higher rates of postoperative PEDVT if appropriate and timely antithrombotic measures are not communicated and instituted.
Conversely one could also argue that accidental punctures/lacerations would increase with increased fatigue. More study, as they say, is required. Several issues are brought up in the discussion (the paper was presented at the Southern Surgical Association meeting):
Dr. Josef E. Fischer (Boston, Massachusetts): I would like to congratulate the authors for addressing this issue from the standpoint of surgical training programs because heretofore all of the data that we have seen have been from either single institutions or have been associated with medical programs.
I think you are all aware of the fact that recently in the New England Journal of Medicine, Czeisler and his group from Brigham and Women's Hospital published a paper concerning medical ICU with the interns that seemed to have less than adequate supervision and the number of errors they made after a certain period of time on duty.
I was interviewed for the Wall Street Journal by Laura Landrau, who is one of the very well-respected assistant managing editors, and pointed out to her that I thought that the authors had a vested interest and a conflict, basically because all of the previous work was based on the fact that there was such a problem, and that I thought what the outcome really reflected was the fact that, in a largely unsupervised medical ICU setting with a raw, new medical intern, this was an expected outcome without senior supervision and that in a surgical service in which there is senior supervision at most or all times, the results might be different.

Unfortunately, the only thing that was quoted of our fairly long interview was the fact that I thought that 90 to 92 hours was a necessary period of time for continuity of care, and this is the result of the studies that Bob Bower carried out in Cincinnati, and that was our data. I got into a fair amount of trouble with that quote in the People's Republic of Massachusetts, which seems to be somewhat different from the rest of the country.

And yet this paper, I think, asks several cogent questions. But I have a little difficulty with the parameters such as those chosen because I think the basic issue, at least for a surgical service, is continuity of care. And, I have difficulty, as does Dr. Bland, transposing continuity of care into the observed outcome.

So my questions for the authors are: Are there other parameters that are more closely linked to continuity of care? Or are there other questions that the authors asked that were not particularly answered by the types of parameters that were chosen? Because I think certainly for a surgical service, continuity of care is the basic issue, an issue that is still out there and needs to be answered.

That paper was discussed here. And this is a point I have made repeatedly concerning the 80-hour workweek:
Dr. Thomas R. Gadacz (Augusta, Georgia): There are several issues about the 80-hour work week. First, the 80-hour work week is mandated for all residency training programs. Second, what is an 80-hour work week and how are those 80 hours spent? Can we have an 80-hour plus work week and structure it so that patient care is not fragmented and fatigue and medical errors avoided? Third, what work effort can residents expect once they enter practice?

Although we haven't analyzed all the data, we are completing a survey from the Southeastern Surgical Congress on the work hours of physicians in practice. A real surprise is the finding that the mean average work hours of surgeons in full-time practice is around 65 hours per week, and 20% of the surgeons in practice exceed 80 hours. I would be very surprised if that is going to change just because the 80-hour work week has been mandated for residents. Surgery residents going into practice may have to work longer than 80 hours per week.

We need to design a work hour week that is not totally dependent upon total hours and allow sufficient rest to prevent impairment because of sleep deprivation. Surgeons in practice seem to have better control of their hours to avoid exhaustion. We need to design systems within the residency program that can control the fatigue component and simply not just focus on the 80-hour work week.[emphasis mine]

More to come, I'm sure.
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