The Impact of Resident Work-Hour Restrictions on Outcomes of Cardiac Operations

Gopaldas, Raja R.; Huh, Joseph; Bakaeen, Faisal G.; Wang, Xing Li; Coselli, Joseph S.; LeMaire, Scott A.; Chu, Danny

doi:10.1016/j.jss.2009.03.042

Cited by 19 publications

(22 citation statements)

References 19 publications

(18 reference statements)

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“…This phenomenon could partially explain the increase in the number of cardiac surgery patients that remained on ventilators for >48 h in one of our studies. 90 A third possibility is that these inconsistencies simply represent variation due to local factors or chance. For example, the complication of postoperative pneumonia was increased in one study 67 and lessened in another.…”

Section: Discussionmentioning

confidence: 99%

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

2011

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), bibliographies, pertinent reviews, and meeting abstracts. STUDY SELECTION: We 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 EXTRACTION: One 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. RESULTS: Of 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. Metaanalysis 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. LIMITATIONS: Most 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. CONCLUSIONS:Since 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.

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Section: Discussionmentioning

confidence: 99%

Patient Safety, Resident Education and Resident Well-Being Following Implementation of the 2003 ACGME Duty Hour Rules

2011

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“…34 Interestingly, this study was performed by the same group of researchers that had reported mortality improvement in a smaller, institution-based study the previous year. 27 These data reveal mixed outcomes with regard to patient safety and underscore the potential for unintended consequences from restricting resident duty hours. One explanation is that restricted resident duty hours increased the number of transitions in patient care between physicians, which may offset or even outweigh any potential improvements linked to better rested residents.…”

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confidence: 98%

“…Observational studies have shown decreases in all-cause mortality 23,27 and in the frequency of ''complications due to the provider'' 23 in the period following implementation of resident duty hour limits, but these outcome measures are nonspecific in delineating the role of duty hour restrictions in directly improving patient outcomes. Furthermore, although each study controlled for patient-specific confounders, without comparing to nonteaching hospitals as controls, it is unclear whether the improved outcomes seen were mainly due to limited resident duty hours or to advances in technology or to other initiatives, which contributed to improved patient safety across hospitals as a whole.…”

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confidence: 99%

A Narrative Review of Surgical Resident Duty Hour Limits: Where Do We Go From Here?

Fabricant¹,

Dy²,

Dare³

et al. 2013

Journal of Graduate Medical Education

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Background Resident duty hour limits have been a point of debate among educators, administrators, and policymakers alike since the Libby Zion case in 1984. Advocates for duty hour limits in the surgical subspecialties cite improvements in patient safety, whereas opponents claim that limiting resident duty hours jeopardizes resident education and preparedness for independent surgical practice. Methods Using orthopaedic surgery as an example, we describe the historical context of the implementation of the duty hour standards, provide a review of the literature presenting data that both supports and refutes continued restrictions, and outline suggestions for policy going forward that prioritize patient safety while maintaining an enhanced environment for resident education. Results Although patient safety markers have improved in some studies since the implementation of duty hour limits, it is unclear whether this is due to changes in residency training or external factors. The literature is mixed regarding academic performance and trainee readiness during and after residency. Conclusion Although excessive duty hours and resident fatigue may have historically contributed to errors in the delivery of patient care, those are certainly not the only concerns. An overall “culture of safety,” which includes pinpointing systematic improvements, identifying potential sources of error, raising performance standards and safety expectations, and implementing multiple layers of protection against medical errors, can continue to augment safety barriers and improve patient care. This can be achieved within a more flexible educational environment that protects resident education and ensures optimal training for the next generation of physicians and surgeons.

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“…No convincing data has been published at the time I write this commentary, demonstrating improved outcomes directly related to work hour restrictions. Using a large computerized database of cardiac surgery patients, Gopaldas and colleagues have examined this issue in the current study [3]. The stated conclusion that cardiac operations performed after the resident work hour restrictions went into effect were associated with significantly decreased mortality rates is misleading, in my opinion.…”

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confidence: 90%