Resident work-hour limits don’t increase patient mortality

Limiting residents’ hours has not increased patients’ mortality risk, but it may be leading to less time spent with patients, say two studies in the August issue of the Journal of General Internal Medicine.

The Accreditation Council for Graduate Medical Education limited resident hours twice in an effort to prevent errors from fatigue — once in 2003, with a cap of 80 hours a week, and again in 2011, when it cut residents’ maximum shift length from 30 hours to 16.

Critics argued that residents would lose training time and patients would be transferred among more health professionals, increasing the risk of harming patients and breaking continuity of care.

That’s not what University of Pennsylvania researchers found. They studied 13.7 million Medicare patients admitted to hospitals for acute myocardial infarction, gastrointestinal bleeding, congestive heart failure, and general, orthopedic or vascular surgery between 2000 and 2008. They found no significant difference in mortality within 30 days of admission in the first three years after the 2003 reform and improvement in mortality rates in years four and five (link).

“We can reassure the public that patients did not appear to be harmed by the initial duty hour reform of 2003,” said senior study author Jeffrey Silber, MD, PhD, professor of health care management at the University of Pennsylvania. He added that although mortality rates did improve in years four and five, researchers could not say definitively that the improvement was due to the reforms and not other factors.

Dr. Silber said that although the study measures only mortality, “we have published many papers prior to this looking at other outcomes [including prolonged length of stay following 2003 duty hour reform], and we have found similar results.”

Dr. Silber said the researchers next will look at whether changes in residents’ shift length affected patient outcomes or educational performance.

Ingrid Philibert, PhD, senior vice president in the department of field activities at the ACGME, said the organization supports further study.

“These findings offer support for the duty-hour limits,” she said in an email. “The most significant limitation in the results offered are associations, not a clear determination of a cause and an effect. The lag time between the implementation of the standards in 2003 and the effect on patient outcomes suggests that the positive effect of the standards on safety and quality of care may have required changes in care patterns that required some time for hospitals to implement.”

Where residents’ time goes

A second study in the August issue of JGIM explored how medical residents were spending their time after the restrictions on work hours.

Researchers at Johns Hopkins University and the University of Maryland observed 29 internal medicine residents over three weeks in 2012 at two large hospitals in Baltimore. They recorded the actions anonymously and found that residents spent less time in direct patient care than residents did before the limits on hours (link).

In the 2012 study, residents spent 12% of their time (8 minutes per patient per day) on direct patient care; 64% in indirect patient care (talking with other health professionals, reviewing charts, handoffs, etc.); 15% in educational activities (including conferences and teaching); and 9% in miscellaneous activities such as sleeping, walking and eating. Residents used computers 40% of their working hours. Researchers accounted for multitasking.

Previous studies in 1989 and 1993 cited by the researchers found that residents spent 18% to 22% in direct patient care; 42% to 45% documenting; and up to 40% of their time doing “miscellaneous” activities such as sleeping and eating.

Lead study author Lauren Block, MD, MPH, now assistant professor of at Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y., said the duty hours were not likely solely responsible for reduced time with patients, but were a contributing factor with increasingly complex regulations and data collection.

She said researchers found that even though residents aren’t spending nearly as much time sleeping or eating at hospitals as they did in previous decades, “that time is not being made up spending time with patients, because they spend that time instead working at their computer stations.”

Researchers concluded that program directors, hospital administrators and legislators must find ways to help residents carve out more time with patients. Dr. Block said possible strategies include: capping the number of patients that residents can have on their shift; assigning a resident to patients in the same geographical area of a hospital so the resident spends less time walking; and improving efficiency in electronic health records.