Less work hours do not improve surgical patient safety

Photo: Young surgeon sleeping in a wheelchair

The 2011 policy limits first-year residents to working at most 16 hours continuously; ©panthermedia.net/ luislourobd

Work hour restrictions for resident physicians, revised nationally four years ago largely to protect patients against physician trainees' fatigue-related errors, have not had the desired effect of lowering postoperative complication rates in several common surgical specialties, according to new study results.

The study was published on the Journal of the American College of Surgeons website in advance of print publication later this year.

There was no significant difference in measured surgical patient outcomes between one year before and two years after the 2011 resident duty hour reform was implemented by the Accreditation Council for Graduate Medical Education (ACGME) according to the study authors. The ACGME is the accrediting and standards-setting body for about 9,500 U.S. medical residency programs. Residents are medical school graduates who are training in a specialized area of medicine, including surgery.

The investigators evaluated outcomes within 30 days of an operation - a combined measure of patients' deaths and serious complications - in five surgical specialties: neurosurgery, obstetrics/gynecology, orthopedic surgery, urology, and vascular surgery. The number of patients included in this retrospective study ranged from 22,158 in urology to 61,640 in vascular surgery during the three-year period examined.

"This study adds to the body of medical literature showing no strong association between resident duty hour reform and change in postoperative outcomes," said lead investigator Ravi Rajaram, MD, MSc, a Resident Clinical Scholar at the American College of Surgeons (ACS) and a fellow with the Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Ill. "Our finding suggests the ACGME reform is not meeting its goal of improved patient safety in surgery."

Prior studies found that the 2011 ACGME duty hour reform did not affect patient outcomes among general surgical patients. However, Rajaram said the workload changes might have affected surgical specialties differently than general surgery. "Our study is the first to examine the association of the 2011 resident duty hour reform and patient outcomes among specific surgical specialties for two years after the policy changes took effect," he explained.

On July 1, 2011, the ACGME made the first changes to resident duty hours since its 2003 major reform. The 2011 policy limits first-year residents to working at most 16 hours continuously and requires they be directly supervised by senior physicians at all times when in-house. These new standards also mandate at least 14 hours off work after a 24-hour shift. Additionally, residents working 24-hour shifts may spend no more than four hours (instead of the former six hours) in transferring patients to another care provider, often called patient "handoffs."

"These restrictions impose obstacles for residents and their residency programs," Rajaram said. "Under the new policies, residents are handing off patients more often, and patient handoffs are one of the most common preventable causes of serious patient harm events."

During transitions in care of a surgical patient, such as moving from the operating room to the recovery room, a health care provider must communicate important patient information to the new care provider. According to the Joint Commission, at least half of communication breakdowns occur during handoffs, and communication problems are responsible for nearly 70 percent of "sentinel events" - serious harm to the patient.

MEDICA-tradefair.com; Source: American College of Surgeons

More about the ACS at: www.facs.org