Why Residents Consider Working Beyond the Duty Hour Limits: Implications of the ACGME 2011 Duty Hour Standards.
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SUBMITTER: Fletcher KE
PROVIDER: S-EPMC3244329 | biostudies-other | 2011 Dec
REPOSITORIES: biostudies-other
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Project description:Patient outcomes associated with the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour reforms have not been evaluated at a national level.To evaluate the association of the 2011 ACGME duty hour reforms with mortality and readmissions.Observational study of Medicare patient admissions (6,384,273 admissions from 2,790,356 patients) to short-term, acute care, nonfederal hospitals (n?=?3104) with principal medical diagnoses of acute myocardial infarction, stroke, gastrointestinal bleeding, or congestive heart failure or a Diagnosis Related Group classification of general, orthopedic, or vascular surgery. Of the hospitals, 96 (3.1%) were very major teaching, 138 (4.4%) major teaching, 442 (14.2%) minor teaching, 443 (14.3%) very minor teaching, and 1985 (64.0%) nonteaching.Resident-to-bed ratio as a continuous measure of hospital teaching intensity.Change in 30-day all-location mortality and 30-day all-cause readmission, comparing patients in more intensive relative to less intensive teaching hospitals before (July 1, 2009-June 30, 2011) and after (July 1, 2011-June 30, 2012) duty hour reforms, adjusting for patient comorbidities, time trends, and hospital site.In the 2 years before duty hour reforms, there were 4,325,854 admissions with 288,422 deaths and 602,380 readmissions. In the first year after the reforms, accounting for teaching hospital intensity, there were 2,058,419 admissions with 133,547 deaths and 272,938 readmissions. There were no significant postreform differences in mortality accounting for teaching hospital intensity for combined medical conditions (odds ratio [OR], 1.00; 95% CI, 0.96-1.03), combined surgical categories (OR, 0.99; 95% CI, 0.94-1.04), or any of the individual medical conditions or surgical categories. There were no significant postreform differences in readmissions for combined medical conditions (OR, 1.00; 95% CI, 0.97-1.02) or combined surgical categories (OR, 1.00; 95% CI, 0.98-1.03). For the medical condition of stroke, there were higher odds of readmissions in the postreform period (OR, 1.06; 95% CI, 1.001-1.13). However, this finding was not supported by sensitivity analyses and there were no significant postreform differences for readmissions for any other individual medical condition or surgical category.Among Medicare beneficiaries, there were no significant differences in the change in 30-day mortality rates or 30-day all-cause readmission rates for those hospitalized in more intensive relative to less intensive teaching hospitals in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.
| S-EPMC5546100 | biostudies-literature
Project description:To examine whether hospital financial health was associated with differential changes in outcomes after implementation of 2003 ACGME duty hour regulations.Observational study of 3,614,174 Medicare patients admitted to 869 teaching hospitals from July 1, 2000 to June 30, 2005.Interrupted time series analysis using logistic regression to adjust for patient comorbidities, secular trends, and hospital site. Outcomes included 30-day mortality, AHRQ Patient Safety Indicators (PSIs), failure-to-rescue (FTR) rates, and prolonged length of stay (PLOS).All eight analyses measuring the impact of duty hour reform on mortality by hospital financial health quartile, in postreform year 1 ("Post 1") or year 2 ("Post 2") versus the prereform period, were insignificant: Post 1 OR range 1.00-1.02 and Post 2 OR range 0.99-1.02. For PSIs, all six tests showed clinically insignificant effect sizes. The FTR rate analysis demonstrated nonsignificance in both postreform years (OR 1.00 for both). The PLOS outcomes varied significantly only for the combined surgical sample in Post 2, but this effect was very small, OR 1.03 (95% CI 1.02, 1.04).The impact of 2003 ACGME duty hour reform on patient outcomes did not differ by hospital financial health. This finding is somewhat reassuring, given additional financial pressure on teaching hospitals from 2011 duty hour regulations.
| S-EPMC3626351 | biostudies-literature
Project description:BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour standards restrict continuous duty for postgraduate year (PGY)-1 residents to 16 hours. OBJECTIVE: We aimed to assess the relationship between a duty hour-compliant schedule and resident sleep. METHODS: To comply with 2011 duty hour limits, Beth Israel Deaconess Medical Center restructured its intensive care unit call model for internal medicine PGY-1 residents from a traditional shift model to an overlapping shorter-duration shift model with preserved educational periods. Before and after schedule changes, we used daily surveys of PGY-1 residents to collect self-reported data on quantity and quality of sleep and quality of education. RESULTS: A total of 1162 surveys were sent to 43 interns before scheduling changes, and 1305 were sent to 41 interns after the changes. Response rate was 31.2% (362 of 1161) before and 22.2% (290 of 1305) after. Before changes, 57.7% (209 of 362) reported receiving 6 hours or more of sleep in a 24-hour period compared to 72.4% (210 of 290) after the changes (adjusted relative risk, 1.33; 95% CI, 1.15-1.53), with an adjusted difference of 0.83 hours of sleep per 24 hours (95% CI, 0.28-1.38). After the intervention, on a 5-point Likert scale, residents reported higher quality of sleep (odds ratio [OR], 1.62; 95% CI, 1.01-2.60) and greater satisfaction with their education (OR, 2.59; 95% CI, 1.40-4.81). CONCLUSIONS: Following conversion to a duty hour-compliant model with preserved didactic time, PGY-1 residents reported minor increases in quantity and quality of sleep per 24-hour period, and increased satisfaction with the educational experience.
| S-EPMC4535224 | biostudies-other
Project description: Not available
| S-EPMC4275102 | biostudies-literature
Project description:ObjectiveTo describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.MethodsUS residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.ResultsOf 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).ConclusionResidency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
| S-EPMC3046937 | biostudies-literature
Project description:The American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical Education's (ACGME) Second Resident Duty Hours in the Learning and Working Environment Congress. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony.In 2016 our joint working group of experts in EM medical education conducted a consensus-based, mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv.A total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions, organizational recommendations were crafted and submitted to the ACGME.EM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.
| S-EPMC5785201 | biostudies-literature
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.
| S-EPMC3138977 | biostudies-literature
Project description:BACKGROUND: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted the 24+6-hour work schedule and 80-hour workweek, and in 2011, it enhanced work hour and supervision standards. INNOVATION: In response, Oregon Health & Science University's (OHSU) neurological surgery residency instituted a 3-person night float system. METHODS: We analyzed work hour records and operative experience for 1 year before and after night float implementation in a model that shortened a combined introductory research and basic clinical neurosciences rotation from 12 to 6 months. We analyzed residents' perception of the system using a confidential survey. The ACGME 2011 work hour standards were applied to both time periods. RESULTS: AFTER NIGHT FLOAT IMPLEMENTATION, THE NUMBER OF DUTY HOUR VIOLATIONS WAS REDUCED: 28-hour shift (11 versus 235), 8 hours off between shifts (2 versus 20), 80 hours per week (0 versus 17), and total violations (23 versus 275). Violations increased only for the less than 4 days off per 4-week interval rule (10 versus 3). No meaningful difference was seen in the number of operative cases performed per year at any postgraduate year (PGY) training level: PGY-2 (336 versus 351), PGY-3 (394 versus 354), PGY-4 (803 versus 802), PGY-5 (1075 versus 1040), PGY-7 (947 versus 913), and total (3555 versus 3460). Residents rated the new system favorably. CONCLUSIONS: To meet 2011 ACGME duty hour standards, the OHSU neurological surgery residency instituted a 3-person night float system. A nearly complete elimination of work hour violations did not affect overall resident operative experience.
| S-EPMC4054734 | biostudies-other
Project description:Background?In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted requirements that limited the number of hours residents could spend on duty, and in 2011, it revised these requirements.Objective?This study explored whether the implementation of the 2003 and 2011 duty hour limits was associated with a change in emergency medicine residents' performance on the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE).Methods?Beginning with the 1999 QE and ending with the 2014 QE, candidates for whom all training occurred without duty hour requirements (Group A), candidates under the first set of duty hour requirements (Group C), and candidates under the second set of duty hour requirements (Group E) were compared. Comparisons included mean scores and pass rates.Results?In Group A, 5690 candidates completed the examination, with a mean score of 82.8 and a 90.2% pass rate. In Group C, 8333 candidates had a mean score of 82.4 and a 90.5% pass rate. In Group E, there were 1269 candidates, with a mean score of 82.5 and an 89.4% pass rate. There was a small but statistically significant decrease in the mean scores (0.04, P?<?.001) after implementation of the first duty hour requirements, but this difference did not occur after implementation of the 2011 standards. There was no difference among pass rates for any of the study groups (?2?=?1.68, P?=?.43).Conclusions?We did not identify an association between the 2003 and 2011 ACGME duty hour requirements and performance of test takers on the ABEM QE.
| S-EPMC5058589 | biostudies-literature
Project description:BackgroundThe Accreditation Council for Graduate Medical Education duty hour requirements may affect residents' understanding and practice of professionalism.ObjectiveWe explored residents' perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.DesignAnonymous cross-sectional survey.ParticipantsInternal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).MeasurementsUsing Likert scales and open-ended questions, the questionnaire explored the following: residents' attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.ResultsOne hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing professionalism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.ConclusionsResidents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.
| S-EPMC1924703 | biostudies-literature