Limits set by the Accreditation Council for Graduate Medical Education on duty hours for residents may have changed aspects of trauma care, according to Rhode Island-based researchers.
Most studies on the topic of duty hours have focused on the policy’s effect on mortality and serious morbidity, and have identified no significant changes,” said Jayson S. Marwaha, a medical student at Warren Alpert Medical School of Brown University, Providence. “However, our findings demonstrate that limiting duty hours may influence the quality of patient care when specialty-specific metrics are studied,” he told Reuters Health by email.
Marwaha and colleagues, whose findings appeared online in The Journal of the American College of Surgeons, studied trauma center data on more than 11,700 admissions from 2009 to 2013. Among provisions of the 2011 reforms for all U.S. residency programs are that first-year residents should have shifts no longer than 16 hours with at least eight off-duty hours between shifts. More senior residents with 24-hour shifts are allowed a maximum of four hours for transfer of care activities, and at least 14 off-duty hours between shifts.
Although the researchers found no significant changes in outcomes, including death, after adoption of the reforms, the length of hospital stay fell significantly from 7.98 days to 7.36 days (p=0.01). In addition, there was a significant rise in operating room and bedside procedures such as imaging and chest tube placement per admission (6.72 to 7.34, p<0.001) and in OR visits per admission (0.76 to 0.91, p<0.001).
Overall, there were an additional 9,559 procedures and 1,584 OR visits after the reforms. The most significant increases were in bedside procedures including lab and imaging. The mean number of consults per admission was also significantly higher in the post-reform group (1.42 vs. 1.02, p<0.001). The mean number of missed injuries per admission was significantly lower (0.40 vs. 0.68, p=0.036), but further evaluation indicated that the observed improvements in missed injuries were not associated with the reform.
The researchers note that, “Whether better metrics exist for examining the effects of work hour limitations on practice patterns and quality is uncertain; further study should be done to identify specific metrics affected by the reform.” In fact, they suggest that “less-commonly studied areas of quality in the context of the 2011 duty hour reform, such as the cost of care, should be further studied.”
Commenting on the findings by email, Dr. Anthony Yang told Reuters Health that although there was no change in patient deaths or complications, the reforms have had other consequences.
“Specifically,” said Dr. Yang, of the Surgical Outcomes and Quality Improvement Center of Northwestern University Feinberg School of Medicine, Chicago, the study reveals “a previously unidentified pattern of increased use of healthcare resources in trauma patients. The new finding in this study adds more evidence and nuance to the debate over duty hour restriction policies for resident physicians.”
Dr. Yang was not involved in the study.