Dataset Information

Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.

ABSTRACT:

Background

The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial.

Methods

We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review.

Results

The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors.

Conclusions

Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts. (Funded by the National Heart, Lung, and Blood Institute; ROSTERS ClinicalTrials.gov number, NCT02134847.).

SUBMITTER: Landrigan CP

PROVIDER: S-EPMC7405505 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.

Landrigan Christopher P CP Rahman Shadab A SA Sullivan Jason P JP Vittinghoff Eric E Barger Laura K LK Sanderson Amy L AL Wright Kenneth P KP O'Brien Conor S CS Qadri Salim S St Hilaire Melissa A MA Halbower Ann C AC Segar Jeffrey L JL McGuire John K JK Vitiello Michael V MV de la Iglesia Horacio O HO Poynter Sue E SE Yu Pearl L PL Zee Phyllis C PC Lockley Steven W SW Stone Katie L KL Czeisler Charles A CA

The New England journal of medicine 20200601 26

<h4>Background</h4>The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial.<h4>Methods</h4>We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians th ...[more]

PMID: 32579812

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Project description:BackgroundConcern persists that extended shifts in medical residency programs may adversely affect patient safety.MethodsWe conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.ResultsThe change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.ConclusionsAllowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).

Project description:ContextThe ACGME-released revisions to the 2003 duty hour standards.ObjectiveTo review the impact of the 2003 duty hour reform as it pertains to resident and patient outcomes.Data sourcesMedline (1989-May 2010), Embase (1989-June 2010), bibliographies, pertinent reviews, and meeting abstracts.Study selectionWe included studies examining the relationship between the pre- and post-2003 time periods and patient outcomes (mortality, complications, errors), resident education (standardized test scores, clinical experience), and well-being (as measured by the Maslach Burnout Inventory). We excluded non-US studies.Data extractionOne rater used structured data collection forms to abstract data on study design, quality, and outcomes. We synthesized the literature qualitatively and included a meta-analysis of patient mortality.ResultsOf 5,345 studies identified, 60 met eligibility criteria. Twenty-eight studies included an objective outcome related to patients; 10 assessed standardized resident examination scores; 26 assessed resident operative experience. Eight assessed resident burnout. Meta-analysis of the mortality studies revealed a significant improvement in mortality in the post-2003 time period with a pooled odds ratio (OR) of 0.9 (95% CI: 0.84, 0.95). These results were significant for medical (OR 0.91; 95% CI: 0.85, 0.98) and surgical patients (OR 0.86; 95% CI: 0.75, 0.97). However, significant heterogeneity was present (I(2) 83%). Patient complications were more nuanced. Some increased in frequency; others decreased. Outcomes for resident operative experience and standardized knowledge tests varied substantially across studies. Resident well-being improved in most studies.LimitationsMost studies were observational. Not all studies of mortality provided enough information to be included in the meta-analysis. We used unadjusted odds ratios in the meta-analysis; statistical heterogeneity was substantial. Publication bias is possible.ConclusionsSince 2003, patient mortality appears to have improved, although this could be due to secular trends. Resident well-being appears improved. Change in resident educational experience is less clear.

Project description:ImportanceWhile the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety.ObjectiveTo determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes.Design, setting, and participantsThis 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program.InterventionsTwenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order.Main outcomes and measuresThe primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings.ResultsOf the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04).Conclusions and relevanceIncreased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.Trial registrationClinicalTrials.gov Identifier: NCT03318198.

Project description:BackgroundDiabetic patients are more likely to develop kidney stones than the general population. The underlying mechanisms for this disparity remain to be elucidated. Little is known about the relationship between urine composition and diabetes mellitus in non-stone-forming individuals. We sought to examine the differences in the 24-hour (24-h) urine composition between diabetic and non-diabetic adults who were not stone formers.MethodsA convenience sample of 538 individuals without a history of nephrolithiasis, gout, hyperparathyroidism, or gastroenteric diseases participated in this study. The 24-h urine profiles of 115 diabetic adults were compared with those of 423 non-diabetic adults. Diabetes was defined by self-reported physician diagnosis or medication use. All participants were non-stone formers confirmed by urinary tract ultrasonography. Participants provided a fasting blood sample and a single 24-h urine collection for stone risk analysis. Student's t-test was used to compare mean urinary values. Linear regression models were adjusted for age, gender, body mass index, hypertension, fasting serum glucose, serum total cholesterol, estimated creatinine clearance rate and urinary factors.ResultsUnivariable analysis showed that the diabetic participants had significantly higher 24-h urine volumes and lower urine calcium and magnesium excretions than non-diabetic participants (all P < 0.05). After multivariate adjustment, no significant differences in 24-h urine composition were observed between diabetic and non-diabetic participants except for a slightly increased 24-h urine volume in diabetic participants (all P > 0.05). The main limitation of this study is that the convenience samples and self-reported data may have been sources of bias.ConclusionOur data showed that there were no differences in 24-h urine composition between diabetic and non-diabetic adults who are not stone formers. The reason for it might be the improved glycemic control in diabetic individuals in our study. Therefore, a tighter glycemic control might reduce stone formation in diabetic adults.

Project description:INTRODUCTION: Few studies investigate the benefits of familiarity or continuity during physician-to-physician handoff of inpatients. Factors such as how recently physicians (MDs) have worked and successive days caring for patients increase continuity, and thus could lead to enhanced handoff efficiency. Evaluating the efficacy of MD scheduling to enhance continuity is currently subjective. METHODS: An MD group consisting of 9 attending physicians and 7 fellows redesigned its pediatric intensive care unit (PICU) coverage schedule with the goal of enhancing continuity of care. The attending PICU MDs were formally surveyed to rate the impact of the schedule change on continuity and efficiency (5 point Likert scale: 1 = worse, 3 = no change, 5 = better). A Handoff Continuity Score (HCS) was developed and used to analyze the 30-bed PICU MD schedule for continuity and handoff efficiency. MD service and call schedules were evaluated for 6-month periods before and after the schedule redesign. The HCS for each schedule was calculated by considering every shift change, or handoff, in the scheduling horizon, and assigning scores to oncoming physicians based on previous days worked. Specifically, for each handoff, each oncoming MD receives a score between 0 and 1, calculated as the summation of a series of 'familiarity factors', one for each recent day worked. The scores for all oncoming MDs are averaged to determine the score for that specific handoff, and the HCS is the average of all handoff scores. The HCS was incorporated into an integer programming (IP) model for scheduling MDs to maximize continuity. A z-test was used to assess the significance of improvement in the HCS. RESULTS: The HCS before and after redesign was 0.57 and 0.68, respectively (19% increase, p < 0.01). Mean MD rating was 4.22 ± 0.56 for continuity, and 4.00 ± 0.65 for efficiency. With the goal of further improving the HCS and (partly) automating and streamlining the scheduling process, the IP was developed to populate physician service and night-call schedules while conforming to scheduling constraints; IP-generated schedules improved the HCS to 0.79 (39% increase). CONCLUSIONS: The increased HCS was associated with the MD qualitative assessment of enhanced continuity and efficiency after implanting a schedule change. The IP identified the potential for additional scheduling improvements.

Dataset Information

Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.

Background

Methods

Results

Conclusions

Publications

Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.

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