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.

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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