Do resident work-hour restrictions increase surgical complications?

by Chris Emery, Contributing Writer, MedPage Today

Reductions in resident physician work-hours at teaching hospitals in 2003 were associated with an increase in complications related to surgery to repair hip fractures, a new study found.

Do resident work hour restrictions increase surgical complications? The rates of pneumonia, hematoma, renal complications, and blood transfusions associated with hip surgery rose disproportionally at teaching hospitals compared to other hospitals after resident duty hour reforms were implemented (P<0.001, P=0.1455, P<0.001, and P<0.001, respectively), according to a report in the Sept. 1 issue of Journal of Bone and Joint Surgery.

“Resident performance and health-care delivery are complex processes, particularly within the intricate system of a teaching hospital,” James A. Browne, MD, of Duke University Medical Center, and colleagues wrote.

“Our investigation identified that the rate of change of perioperative morbidity in patients with a hip fracture increased significantly in teaching hospitals following resident duty-hour reform.”

On July 1, 2003, the Accreditation Council for Graduate Medical Education in the United States set a maximum of 80 duty hours per week for orthopaedic surgery residents. Reforms also stipulated that residents must have one day in seven free from all educational and clinical responsibilities, and a 10-hour break between all daily duty periods and after being on call in the hospital.

In-house calls were limited to once every three nights and to 24 hours with a six-hour extension for continuity of care, the authors noted.

“These changes were implemented in an attempt to reduce resident fatigue in order to improve resident education and patient safety,” they added

Although recent studies have shown that the reforms indeed reduced residents’ fatigue, there was mixed data about how the rule changes affected patients, and there were no studies of the impact on orthopaedic patients at teaching hospitals, the authors noted.

So Browne and colleagues compared the surgical outcomes from before (2001 to 2002) and after (2004 to 2005) the reform was implemented by reviewing records from the Nationwide Inpatient Sample for 48,430 patients treated for hip fractures at teaching and non-teaching hospitals across the United States.

In addition to higher-rates of complications, the study found a rise in non-routine discharges, medical costs, and length of stay in patients who underwent treatment for a hip fractures at teaching hospitals after the reforms were implemented.

The researchers suggested that the reforms mean fewer doctors are available in a hospital at any given time, so that residents have to care for more patients during a shift, and fewer senior-level doctors are available to supervise junior residents. The shorter shifts also mean that patients are handed off between doctors more often.

“It is our anecdotal experience that continuity of care has become more challenging in the orthopaedic teaching environment following duty-hour limitations,” the authors wrote. “Handoffs, particularly problematic in patient care and known to increase the risk of adverse events, appear to occur relatively more frequently in the surgical services after reform.”

Although they attempted to control for confounding factors, the authors cautioned that differences in patient characteristics and treatments between teaching hospitals and other hospitals could have influenced the results.

They also noted that the database they used did not report adverse events that occur after patients are discharged from the hospital and may have inaccurately classified some hospitals as teaching facilities.

“Finally, we only analyzed a limited time period soon after duty-hour restrictions were implemented, and the higher incidence of complications may reflect experimentation by the teaching programs with various strategies to accommodate to the changes,” they wrote.

“This association may not hold up over time as systems are implemented to effectively deal with duty-hour restrictions.”

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  • Doc99

    The road to hell is paved with good intentions.

  • Chris

    So increase the attendings’ work hours, right? How come that’s never a solution?

    I don’t care if there’s an increase in errors. It was completely inhumane to do Q2 in-house call with no 30 hour restriction. PERIOD. There would be no hand-offs ever if the physician just moved into the patient’s house. So why don’t we do that?

  • http://askanmd.blogspot.com/ Doctor D

    An association doesn’t prove causation. Complications that year could have increased for any number of reasons that has nothing to do with limiting resident’s brutal hours.

    I know the unspoken rule where I was at that time was that surgery residents were expected to keep working long hours and lie on their time sheets. What if the long hours added to pressure from your superiors to be dishonest is the cause of the worse outcomes?

  • http://psychcentral.com/blog/ John M. Grohol, PsyD

    Seriously, does anyone do any actual reviewing in peer-reviewed journals any more?

    Of course you would expect a temporary rise in problems associated from moving from one type of system (overworking residents as though they were slaves or indentured servants) to another type of system (humane and civilized working hours). What kind of dumb researcher would expect the outcomes to remain the same??

    The key is that the increase in problems is temporal and temporary. Once implemented and everyone gets used to the system, then you will start seeing improvements in care.

    Change comes with problems during the change. But is that a reason not to change? If that’s the case, every therapist would be out of a job tomorrow.

    Do this study 5 years after implementing humane working conditions for doctors, and then let’s see the data.

  • PICUDoc

    I do thing the handoff issue is a big part of it. Since residents can’t stay for the post call day there’s a lot of signing out/handing off/cross covering. When a resident is in “cross-cover” mode they are just there to babysit, no major changes in the direction of care are made so if a resident is cross covering a patient and a development occurs where a patient may discharged that may get put off until the next day. Also with cross covering the residents don’t know the patients as well since they haven’t taken care of any one patient for a continuous length of time.

    Overall my suspicious is that with going to the 80 hour work week we’ve gotten rid of errors due to fatigue and replaced them with errors due to lack of continuity.

    One option to fix this is a night float/day float system. With having the same resident on call every night for a week you get to know the patients well and feel more comfortable making changes at night.

    The problem with this is that it takes more residents to cover a unit with night float than it does using traditional means. Also, there is the issue of didactic education. During the week of night float the resident will miss out on all the day time educational activities.

  • throckmortons

    I am not sure if this is affecting the trend, but I have seen more and more of the care that was performed by residents being taken over by ARNPs.

  • Jimmy Z

    The real motive behind this is MONEY masquerading under the guise of “patient care.” Because it hospital and programs lose money when their slaves have to be given food and sleep, they sponsor studies showing how patients suffer. Any logical, compassionate person recognizes that even 80 hour work week is too much. It is a lame testament to those programs that couldn’t get their sh** together and perform a normal change of watch, like most competent industries are capable of.

  • http://www.limemedical.com John Bader

    I agree with PICUDoc (#5) that the increased number of handoffs has something to do with the increase in surgical complications. In fact, handoffs are coming under increased scrutiny by the Joint Commission and medical specialty associations for their effect on patient safety. A 2006 study by the Joint Commission, the independent body that accredits U.S. hospitals, found that 67% of all hospital sentinel events (patient death or serious injury unrelated to illness) were caused by improper physician communication, i.e. some sort of breakdown in the handoff. The 800 such events the commission identified in 2008 were double the figure for 2002.

    More anecdotally, as a maker of an iPhone patient signout/handoff tool for physicians, my company sees a movement among hospitals to replace longstanding, ad-hoc ways of passing patient handoff information with a standardized process that captures and keeps the pertinent Dx and treatment plan information. There is a busy and growing business for us and our competitors in supplying healthcare technology designed to do this.

    The patient handoff has even attracted the attention of the mainstream press. The NY Times Well Blog posted on the topic Thursday and drew dozens of comments, many from physicians (http://well.blogs.nytimes.com/2009/09/03/in-medicine-the-perils-of-the-handoff/).

    I’d love to see thoughts from other physicians on this topic. Has the increased number of handoffs resulting from fewer hours being worked by residents had a noticeable effect on patient safety?

    (Full disclosure: my company, Lime Medical, makes a mobile patient signout/handoff product)

  • alex

    This study is almost hilariously bad. It’s an example of database mining to try to send a message; I’m not sure it’s possible to come up with a study design with more potential confounders. Yes, let’s take hospitals at two different time periods, assume the only possible difference besides the handful of factors we can control for is the 80 hour work week (which surgical residents routinely ignore anyway) and then attribute any differences to that. I can literally think of a half dozen other explanations off the top of my head — maybe the trend towards more complicated cases turfed to academics is growing. Maybe they’re correct though — we’re somehow the only country in the world so incompetent that doctors working less than 100 hours a week is a disaster. That’s certainly a palatable hypothesis.

    Just a terrible piece of “research”.

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