Changes to the resident work duty guidelines have been a much-debated topic within the medical community over the past decade: How many hours should residents be on duty and under what kind of supervision? When residents change shifts, how should the hand-off to another physician be handled? Can alertness strategies, such as napping, reduce fatigue-fueled mistakes?
In an effort to get answers to these and other questions, investigators, led by Lori A. Schuh, MD, of the Henry Ford Hospital in Detroit, MI, studied outcomes for 34 residents and faculty at three medium to large neurology residency programs — Henry Ford Hospital, the University of Florida, and the University of Virginia — with 4-6 residents in each year of training. All followed the 2003 Accreditation Council for Graduate Medical Education (ACGME) rules for a control month — which limited shifts to 24 hours with a 6-hour transition period for all residents, and suggested 10-hour rest between all duty periods and after in-house call — and for one month, the work-duty guidelines, which had been recommended by the Institute of Medicine (IOM) in 2008; for example, the IOM had suggested limiting shifts to 16 hours or 24 hours with a five-hour nap and increased time off between shifts for night float and overnight call. (For complete IOM guidelines, see: http://bit.ly/bYQIo5.)
The investigators reported in the July 27 online edition of Neurology that the larger programs could successfully implement the IOM duty hour limits, but the residents indicated that they were less satisfied with their quality of life (QOL) and education, according to Dr. Schuh, neurology residency program director at the Henry Ford Hospital and chair of the AAN Education Research Subcommittee, and colleagues.
Dr. Schuh, who is also a member of the ACGME Neurology Review Committee, said the declines in QOL were related to heightened stress over increased number of patient handovers, lack of knowledge of patients, and inadequate hand-off information. “We think that was because there were a lot of patient handovers — they actually increased,” which led to residents feeling that they didn't know their patients as well, Dr. Schuh said in a telephone interview with Neurology Today.
In interviews with Neurology Today, neurology residency program directors commented on their experiences with work-duty hours — observing differences in outcomes, depending on the size of their program, the type of call assignment they choose, and other factors. And now programs are dealing with the updated 2011 ACGME guidelines, which reduce maximum duty periods for first year residents to 16 hours, maintain the 24-hour limit for PGY-2 (post-graduate year-2) and above with a reduced transition period of four hours, and require 24 hours off over a seven day period, averaged over four weeks (including at-home call) for all residents.
RESIDENCY DIRECTORS COMMENT
Steven L. Galetta, MD, director of the Division of Neuro-Ophthalmology and residency program director for the department of neurology at the University of Pennsylvania, said the UPenn program has had to make some changes in its work duty hours since July 1. “It's not a huge difference, but the change from 30 to 28 hours [after transition hours were changed from 6 to 4] has reduced the amount of time that the PGY-2s can round on their patients and go to conferences on their post-call day,” he explained.
Faced with the new 2011 ACGME guidelines, Dr. Galetta's residents “begged” not to institute a night float system, claiming it would reduce their quality of life and potentially reduce their education. “Some of our residents just can't tolerate a night float and a change of their circadian rhythm,” he said.
Instead, they found other ways to reduce duty hours. Pre-rounding — the earlier morning rounds when a resident comes in to see his patients and to prepare up-to-date information before formal rounds later that morning — has been eliminated, he noted. In addition, conference time has now been reduced from an hour down to 40-45 minutes. “That time is lost for education and patient care,”
Dr. Galetta said. They piloted these changes during the past spring and they have worked well, though one cannot be sure without further study whether it is affecting patient outcomes.
How relevant is program size when it comes to duty-hours? “Since no small programs joined our study, we don't even know if it would have been possible for them to comply with the IOM guidelines,” Dr. Schuh told Neurology Today.
Anecdotally, directors of two small residency programs told Neurology Today that adhering to the IOM guidelines would be challenging. Rodger Elble, MD, PhD, professor and chair of the neurology department at Southern Illinois University School of Medicine, explained that at his program all PGY-1 residents at his program take call with the chief residents.
Even with the 2011 ACGME guidelines, he said, since PGY-1 can only work 16 hours, after that time, the chief resident takes call alone. “It's disruptive…because it affects PGY-1 residents more than PGY-2,PGY- 3, and PGY-4….My concern is what effect this is having on education — and neurological education in general,” he said.
Juan Ochoa, MD, associate professor of neurology at the University of Southern Alabama, said: “Especially in small programs, it's hard to cover service and provide all the academic activities that are required. That's one of the main reasons that we don't make our residents do in-house calls. I think that our schedule more closely resembles a clinical practice — they learn how to deal with the issues over the phone and come in whenever is needed.”
TRANSITIONS OF CARE
The patient hand-off problem is an issue that may be exacerbated by reduced duty hours — and inefficient information exchange when switching patients can lead to disastrous consequences, several residency program directors said.
Dr. Schuh said that the 2011 ACGME rules made an effort to address transitions of care, ruling that programs must develop systems and education in patient handovers, as well as work to minimize hand-offs. However, no specific methods are prescribed in the guidelines, leaving this task at the discretion of each individual institution.
How are programs doing this? Both the University of Southern Alabama and the University of Pennsylvania are using an online server, accessible to all and updated every time a patient is seen.
Dr. Ochoa said, “I think it's a great system because traditionally with passing around a piece of paper, it may not be complete, or it may be different from one person to another. Instead, this is very standardized: you have the patient name, diagnosis, studies, what you need to do.” He said this has resolved the issue of inadequate information flow within his own institution.
At the University of Southern Illinois, Dr. Elble said, we do have online systems in place, but “there are two people that are absolutely responsible for continuity of care to make sure no one drops the ball — and that's the attending and the chief resident. So we have PGY-1, 2, 3, 4 residents, and a faculty person. The faculty person knows that his or her job that week is the inpatient service — 24/7.”
If you function as a team and look out for one another, then the work will get done, Dr. Elble said. He has not had to worry about continuity of care.
‘SAFER’ STRATEGIES, EDUCATION
One of the defining reasons for initially enacting work duty guidelines was to reduce hospital errors fueled by fatigue or sleep deprivation. The new ACGME guidelines propose using “alertness strategies,” such as strategic napping especially between the hours of 10:00 pm and 8:00 am, in order to improve outcomes.
Henry Ford Hospital uses a system in which, for the residents on call, there is a back up resident available as relief for anyone who feels he may be impaired due to fatigue. In addition, Dr. Schuh said, we educate all residents and faculty on fatigue mitigation through the SAFER module (Sleep, Alertness, and Fatigue Education in Residency).
Also, “we have a concierge service which can provide a quiet room for sleeping (separate from our on call room) for any physician who feels too fatigued to drive home, as well as a driving service” — improving safety, both inside the hospital and out.
Dr. Elble said they have created a nap center for their residents — but, despite temptation, he has not made use of this center. “It might help. I have friends in very high positions that take naps. I don't think there's anything new there.” Dr. Elble was skeptical that these strategies will make a big difference in patient care, reducing medical error, or education.
A real concern, Dr. Elble told Neurology Today, is that while “call schedules become more and more complicated, and as the ACGME requirements are more and more difficult to meet, I think that you will see rotations on neurology becoming more and more optional.”
Within his own program, he has suggested assigning a resident in emergency medicine to neurological cases, as one way to both reduce the workload of the neurology resident on call and train the emergency medicine resident to at least “a level where they could do good evaluations of acute stroke patients that are candidates for tPA.” This would still allow residents to function in the ER during their rotations and deal with other problems, but it would give them some training by a neurologist, Dr. Elble said.
We are working hard to comply with the needs of the residents, while still adhering to the new guidelines, Dr. Galetta said. “We make these changes but we don't really understand the outcomes — and we need to do that, and we're going to do that. But, it takes time to accumulate useful data,” he added.
Dr. Elble agreed, stating that he's in favor of duty hour changes (in theory), but would like to see the proof that they are making a difference. “Where are the data that show that people are learning more, delivering better care, making less mistakes, being educated in the things they are supposed to be educated in? I don't see the data,” he told Neurology Today.
For the task of evaluating the effect of work duty guidelines on faculty, resident, and patient outcomes; Dr. Galetta feels that a larger governing body must take the lead, such as the AAN or the American Neurological Association.
In their paper, Dr. Schuh and investigators noted “with interest” that very few studies examining faculty satisfaction or QOL in response to work-duty hour restrictions have been published. “We believe our results combined with the earlier published results of trial implementation of the IOM recommendations… underscore the concerns of educators that, with respect to WDH [work duty hours] and education, ‘one size does not fit all.’”
Dr. Galetta added: Until now, “we have relied largely on expert opinion and it is really a time to take a serious look at these rules and their effect on outcome measures that we deem important to our profession.”