April 4, 2013

Residents’ reduced hours don’t impact care, education

Restructuring work hours for first-year medical residents to accommodate a 2011 duty hour limit of no more than 16 shift hours substantially increases patient handovers, but doesn’t significantly affect efficiency and quality of care among medical inpatients, a Vanderbilt University Medical Center study has found.

Todd Callahan, M.D., left, discusses a patient’s case with first-year resident Rachel Apple, M.D., Rosette Chakkalakal, M.D., and resident Derek Wade Russell, M.D., in the residents’ lounge on the eighth floor of Vanderbilt University Hospital. (photo by Anne Rayner)

Restructuring work hours for first-year medical residents to accommodate a 2011 duty hour limit of no more than 16 shift hours substantially increases patient handovers, but doesn’t significantly affect efficiency and quality of care among medical inpatients, a Vanderbilt University Medical Center study has found.

A separate Vanderbilt research report also shows that the reduced duty hours don’t negatively affect the quality of the intern’s education.

The patient care study, published in JAMA Internal Medicine on April 1, was led by Neesha Choma, M.D., MPH, assistant professor of Medicine.

It compared a group of patients from July-December 2010, prior to the new 16-hour rule, with patients seen from July-December 2011, after the new regulation from the Accreditation Council for Graduate Medical Education (ACGME) took effect. Patient handovers are defined as instances when one provider hands over the care of the patient to another provider (in this case, resident to resident).

Under the 2011 guidelines, PGY-1 (Post-Graduate Year 1) interns are not permitted to work for more than 16 consecutive hours. PGY-2 residents can work up to 24 consecutive hours.
Residency work hours began to change in 2003 when resident work weeks were limited to 80 hours to improve patient and safety, ending the 120-hour work weeks common during training.

The goal was to reduce medical errors, promote patient safety and improve quality of care. Seven years later the ACGME proposed further changes that called for increased supervision of residents, stronger limits on moonlighting and reduced work hours for first-year residents.

Prior to July 2003, work-hour limits were typically left to the discretion of the supervising physicians of each clinical service. After the ACGME recommended the 80-hour limits that year, it relied on residents to self-report their hours — and any potential violations — to their superiors.

There were a flurry of studies after 2003, looking at the physical and mental fatigue of residents, but few studies have evaluated the 2011 changes.

“These were major structural changes,” said Choma, Executive Medical Director of Quality and Patient Safety for Vanderbilt University Hospital. “Under the new regulations, residents can’t work more than 16 hours of continuous duty, meaning they can’t work day and night. With the prior system, you could arrive in the morning, work overnight and until noon the next day.”

For the eight Department of Medicine teams studied, each shift is a well-defined 13-hour period. The day team comes in at 6:30 a.m. and leaves at 7:30 p.m., at the latest. The night shift comes in at 6:30 p.m. and leaves the next morning at 7:30 a.m.

“That builds in a one-hour overlap time, so there’s one hour of dedicated time that can be used for a really structured, thorough handover,” Choma said.

“Recognizing that these major structural changes were new to Vanderbilt, but also new nationally, we thought it was really important to study the effects of these changes, primarily related to patient care. At the end of the day, how does this affect the patient?”

Patient handovers more than doubled when work schedules prior to 2010 were compared with newer schedules required to meet the new duty regulations.

“Handover communication is an interesting concept,” Choma said. “At face value, you worry about suboptimal communication and discontinuity leading to medical errors. On the flip side, the benefit of handing over to a new provider is another set of eyes on the patient who can potentially recognize and correct lapses in care.

The study looked at about 4,000 adult non-intensive care unit patients on eight Vanderbilt University Hospital services, and tracked observed-to-expected mortality, adverse events, length of stay, 30-day hospital readmission, and also the number of rapid response team calls and code calls (escalations in care). They performed a rapid assessment, looking at about six months of data before and after the changes.

“This was a first look to assess whether the residents’ duty hour changes resulted in any unintended consequences. We found that despite this major restructuring, ultimately there was no adverse effect on patient care, which was reassuring,” said Sunil Kripalani, M.D., M.Sc., associate professor of Medicine and another study author. “As time goes on, we’ll want to re-evaluate with a larger group of patients.

The second study, a research report published in Academic Medicine, looked at the educational aspect of reduced duty hours for internal medicine interns during the same time periods as the patient care study in 2010 and 2011 and found that resident education didn’t suffer.

The report was led by Cecelia Theobald, M.D., instructor of Medicine and a VA Quality Scholars fellow, and Dan Stover, M.D., a former resident who is now a medical oncology fellow at Dana Farber Cancer Institute in Boston.

Both program directors and residents were afraid that their exposure to many different kinds of patients and procedures would be lessened by the reduced hours, Theobald said.

“A survey of program directors was done when the new restrictions came out, and they were really concerned that residents weren’t going to see as many patients; that they wouldn’t get as much experience. There was a lot of talk at the time about whether the length of residencies would have to increase,” Theobald said.

Using Vanderbilt’s KnowledgeMap Portfolio learning management system to capture patient interaction data for their report, they looked at patient volume, note characteristics, exposure to common presenting problems, procedural experience and structured didactic experiences both before and after maximum shift lengths were decreased from 30 hours to 16 hours. Study senior author Joshua Denny, M.D., helped create KnowledgeMap Portfolio.

They found that the interns’ clinical exposure didn’t decrease after the shift length was restricted to 16 hours.

In fact, they saw more patients, produced more detailed notes and attended more conferences following the restrictions.

“There are more unique opportunities to meet new patients than with the old system,” she said. “Our big picture conclusion is, if anything, they seem to be getting more educational exposure than before.”

Theobald said using Vanderbilt’s KnowledgeMap was incredibly beneficial, because it’s able to automatically capture 100 percent of clinical and procedural notes written by residents. “It put us in a really good position to do a much more robust analysis,” Theobald said.

Choma and Theobald said that more study is needed, for both the patient care and resident education aspects of the duty hour changes.

Nancy Brown, Hugh J. Morgan Chair in Medicine, agrees.

“This is an important first look, but only at Vanderbilt. Our residents have a culture of commitment to their patients. So it is not surprising to me that they maintained excellent patient care during a time of transition.”