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Does Resident Hours Reduction Have an Impact on Surgical Outcomes?11

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Background

We assessed the impact of restricting surgical resident work hours as required by the Accreditation Council for Graduate Medical Education (ACGME), on postoperative outcomes.

Materials and methods

The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. Clinical data were collected by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to September 30, 2003 (postintervention). We assessed risk-adjusted observed to expected (O/E) ratios of mortality and prespecified postoperative morbidity for each study period.

Results

In the preintervention period, there were 405 general surgery and 202 vascular surgery cases as compared to 382 and 208 cases, respectively in the postintervention period. There were no significant differences in mortality O/E ratios between the pre- and postintervention periods (0.63 versus 0.60 in general surgery; 0.78 versus 0.81 in vascular surgery; P = 0.90 and 0.94, respectively) or in morbidity O/E ratios (1.06 versus 1.27 in general surgery; 1.47 versus 1.50 in vascular surgery; P = 0.20 and 0.90, respectively).

Conclusion

The restricted resident work hour schedule in general and vascular surgery in our facility did not significantly affect postoperative outcomes.

Introduction

Long hours of work, sleep deprivation, and fatigue have marked surgery residency programs for many years. The rationale for these work schedules has been the time-honored tradition of continuity of care [1, 2]. Most surgery educators argue that demanding schedules have been crucial for learning and for the development of a professional attitude in surgeons. They also argue that continuity of care allows for the development of surgical judgment and is essential to good patient care.

Several studies have challenged this model, based on the proven negative effect of sleep deprivation and fatigue on performance. A meta-analysis performed by Pilcher and his colleagues in 1996 suggested that the mean cognitive performance of young healthy adults who are acutely sleep deprived (defined as lack of sleep within the last 24 h) or chronically sleep deprived (defined as less than 6 h of sleep per night for at least a week) is 1.3 standard deviations or more below the mean cognitive performance of rested subjects [3]. Several experimental studies have documented that fatigue impairs human performance, and may even be equivalent to alcohol intoxication [4].

Surgery residents are not immune to the effects of fatigue and sleep deprivation; their work schedules are demanding, the surgical procedures in which they participate are often lengthy, and their in-house call assignments are frequent. An observational study performed in 1972 videotaped surgery residents performing procedures. Sleep deprived residents showed “operative inefficiency”; these residents needed as much as 30% more time to perform the procedure due to poorly planned surgical maneuvers than rested residents [5]. Other studies reported that the rate of surgical complications is 45% higher if the residents performed the operation on postcall mornings than on regular days [6, 7].

In 1984, an increased public concern surfaced concerning reduced vigilance and performance of overworked residents that may contribute to an increase in medical errors and adverse events. In June 2002, the Accreditation Council for Graduate Medical Education (ACGME) responded to intense public pressure and recommended new and restricted work-hour standards for residency programs, effective no later than July 2003. Work hours were limited to a maximum of 80 h per week averaged over 4 weeks, restricted to 24 h of continuous work (in addition to 6 h for continuity of care). Residents cannot be scheduled for in-house call more than once every three nights, averaged over 4 weeks. In addition, residents must have at least 1 day every week free of all clinical and educational activities.

While most will agree that long work hours and frequent in-house calls contribute to reduced quality of life for residents, the effect of limiting work hours on the quality of patient care is unclear. If reduced work hours for residents lead to an increase in supervision and involvement in patient care by attending surgeons, an improvement in postoperative outcomes may result [8]. If, however, a limited work schedule for residents results in less continuity of care and clinical coverage by residents unfamiliar with the patient, unforeseen adverse consequences for patient care may ensue. A study by Petersen and colleagues in 1994 found that the odds of preventable adverse events for medical inpatients increased after implementation of a “night float” system to provide relief for on-call medical house staff [9].

The effect of a limited work schedule on residents’ professionalism and altruism is also controversial [10]. Many surgeons are concerned over the development of a “shift” mentality among surgery residents. As Drazen and Epstein described it, “We risk exchanging our sleep-deprived healers for a cadre of wide-awake technicians” [11]. Others argue that overworking residents cannot be ethically justified [12].

The goal of this study is to evaluate the effect of restricting resident work hours on the postoperative outcomes of surgery patients.

Section snippets

Methods

The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center (VAMC) implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. The data were collected, analyzed, and validated by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to

Results

The number of residents and postgraduate year (PGY) level, and their rotation schedules (i.e., vacation, rotation length) did not change over the two time periods. Each team consisted of a senior resident (PGY 4 or 5), a mid level resident (PGY 3) and two to three junior residents (PGY 1 and 2). An informal survey of average work hours prior to implementation of the ACGME guidelines varied between 87 and 92 h per week, with no consistent 24 h off clinical duties every week. Some residents

Discussion

The quality of care of patients undergoing general or vascular surgery in the Michael E. DeBakey Houston VAMC, as measured by risk-adjusted mortality and morbidity ratios, was not affected by the implementation of work hour limitations for surgery residents, as mandated by the ACGME. The level of attending surgeon supervision was similar before and after limiting resident work hours.

Identifying all of the factors that affect patient outcomes is a difficult and challenging process. The NSQIP,

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1

The views expressed are solely those of the authors, and do not necessarily represent those of the VA. No competing interests are declared.

3

Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (grant number 045444).

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