Surgery News - February 2008 - (Page 3)

F E B R U A RY 2 0 0 8 • SURGERY NEWS NEWS eraged over 4 weeks. Programs can request an increase of up to 8 hours a week and can apply for exemptions. Residents must also have a minimum rest period of 10 hours between duty periods, 1 in 7 days free from patient care responsibilities, and in-house call no more than every third night, averaged over a 4week period, the standards say. The ACGME says it has issued citations to individual programs for duty hour violations and has done resident surveys that demonstrate a compliance rate of 94%. Others argue, however, that enforcement is inadequate and that an independent body is needed to ensure compliance with the rules. Culture and tradition are so entrenched, they say, that too little has changed and that residents routinely underreport hours for fear of retaliation. “I’m a resident who said one thing on a survey and did another thing in real life,” Dr. Sunny Ramchandani, past chair of the AMA Residents and Fellows Section, told the committee. “I’d have a 30-hour shift, work at least 34 hours, and report 16.” “Changing duty hours means changing everything,” from work flow and coverage strategies to transfer-of-care techniques and the “very fundamentals of how patients are treated” and what residents are responsible for, said Dr. Ethan Fried, director of graduate medical education at St. Luke’s–Roosevelt Hospital Center in New York City. Changes made at Dr. Fried’s hospital mean that a patient may now be admitted by one team of residents, treated by an- Sleep Deprivation Tied to Errors Work Schedules • from page 1 represent the impact on surgical patients and trainees,” Dr. Healy said in an interview, adding that there are differences between medical trainees versus surgical trainees. The 14-member task force, chaired by Dr. L.D. Britt, also an ACS Fellow, is studying the most recent national and international evidence addressing resident work hours and is developing recommendations for presentation to the IOM committee. Members of the ACS task force represent a broad spectrum of the surgical specialties, and most members have served on their respective residency review committees and specialty boards. The ACS has requested and been granted an opportunity to present to the IOM Consensus Committee and is developing a document to address the salient issues and make recommendations aimed at providing highquality care for surgical patients now and in the future. The issue of resident works hours received relatively little attention in the IOM’s 1999 report on medical errors, experts said at the workshop, despite decades of research on the effects of sleep deprivation on human performance. Since then, a host of studies have shown that reductions in work hours can reduce errors, physicians told the committee. A prospective, national survey of more than 2,700 interns, for instance, showed that residents were seven times more likely to report a harmful fatigue-related error when they worked five or more 24hour shifts in a month than when they worked no 24-hour shifts. They were four times more likely to report a fatal error. In a randomized controlled trial, residents had twice as many EEG-documented attention failures at night when working 24-30-hour shifts than when working an “intervention” schedule of a 16-hour maximum. Both studies were led by researchers at Harvard University. Dr. Christopher P. Landrigan, who directs the Sleep and Patient Safety Program at Brigham & Women’s Hospital, said the Harvard research has also shown that residents working 24-30-hour shifts make five times as many serious diagnostic errors as those scheduled to work 16 hours or less. They’re also twice as likely to crash their cars, and they sustain 61% more needlestick injuries, he told the IOM committee. Limits instituted by the American Council on Graduate Medical Education (ACGME) in 2003 mark shifts of 24-30 hours as acceptable. The council’s “common duty hour standards” call for a 24-hour limit on continuous duty, with an additional 6 hours for continuity and the transfer of care, as well as an 80-hour weekly limit av- other, and discharged by yet another. In Europe, physicians and other health care workers are prohibited from working more than 13 hours straight or more than 48-56 hours per week. Here in the United States, Dr. Fried said, “with duty hour restrictions coming at the same time as patient volumes have increased, as acuity (of illness) in teaching hospitals has increased, and even as our treatments have become higher-stakes treatments, we have the perfect storm.” ■ See current and archived issues of online at www.facs.org. And don't miss the exclusive online-only articles available on the Web site. More news is just a click away! Operative Experience Drops Slightly in 80-Hour Work Week B Y J E F F E VA N S Else vier Global Medical Ne ws H O T S P R I N G S , VA . — Operative case experience for general surgery residents continues to be stable or slightly reduced in studies of the effects of the 80-hour work week restrictions, according to research presented at the annual meeting of the Southern Surgical Association. One single-center study found no substantive changes in the percentage of elective cases in which residents participated before and after the work hour restrictions were implemented July 1, 2003. A separate study of the Accreditation Council for Graduate Medical Education’s (ACGME) Statistics Summary reports B and C from the Residency Review Committee for Surgery partially corroborated this finding for cases in which residents were logged as the surgeon, but found substantial declines when they were logged as first assistant and teaching assistant. The duty hour restrictions “were intended to provide better patient care by reducing resident fatigue. In addition, this was to free up more time for residents to have for studying. However, surgical faculty and residents are concerned that this decrease in time spent in the hospital would decrease operative experience as residents on such teams from dropped significantly from 252 to 231 (8.3%). However, the well as patient care education,” four to five. “We believe that this in part ex- mean number of cases residents said Dr. Susanna Shin, a general surgery resident at Eastern Vir- plains the lack of change be- performed as junior-level surginia Medical School in Norfolk. tween the two time periods,” she geons stayed nearly the same: At that school’s general said. Chief residents on those ser- 677 before versus 678 after work surgery service, Dr. Shin and her vices also did not take in-house hour restrictions. If the decrease in the number colleagues found that the overall call and were not “saddled with percentage of elective cases in any limitations to their time avail- of cases handled by residents as which a resident participated able during the day for sched- chief resident surgeon or juniorlevel surgeon is truly related to stayed at 79% for both the 890 uled cases,” she said. In another report, Dr. Charles the duty hour restrictions, the cases with charts available in the year before the restrictions were J. Yeo, professor and chair of overall decline in surgeon cases at all levels is minor, whereimplemented and the as the 8% decline in cas960 cases with charts available in the year af- THE OVERALL DECLINE IN CASES AT ALL es as chief resident surgeon is “more terward. The proportions of LEVELS IS MINOR, BUT THE 8% DECLINE troubling,” said Dr. Yeo, residents who participat- IN CASES AS CHIEF RESIDENT SURGEON an ACS Fellow. The median number ed in a particular proceIS ‘MORE TROUBLING’. of cases reported as first dure before and after the assistant or teaching asduty hour restrictions resistant fell much more. mained similar for nearly all types of procedures per- surgery at Thomas Jefferson Uni- The median number of first asformed by junior-, intermediate-, versity, Philadelphia, and his as- sistant cases decreased by 79% sociates studied the total major from 231 to 49, whereas the meand senior-level residents. After the duty hour restrictions operations reported in the dian number of teaching assisbecame effective, the general ACGME Resident Statistics Sum- tant cases declined by 66% from surgery service at Eastern Vir- mary report B and C during the 67 to 23. Dr. Yeo suggested that if these ginia tried to increase efficiency 2002-2006 academic years. For and distribute work better by residents at any level of training trends continue, the loss of earpaying greater attention to resi- who were logged as being the ly learning exposure as a first asdent case assignments, Dr. Shin surgeon, the mean number of sistant may slow a resident’s acmajor operations declined a sig- quisition of basic surgical skills, said. An additional intermediate-lev- nificant 2.3% from 930 before and the loss of experience as a el resident was added to resident the restrictions to 909 afterward. teaching assistant may reduce auteams for particular surgical ser- For those who performed as a tonomy and opportunities to vices that needed a larger work- chief resident surgeon, the mean teach other residents. But Dr. J. David Richardson, force. This raised the number of number of major operations also professor and vice chairman of surgery at the University of Louisville (Ky.), thought that first assistant and teaching assistant data have “no validity” because about 40% of residents enter a zero for teaching assistant cases during their entire residency, despite the fact that they did obtain experience in such cases. “In an environment in which residents are supposed to be supervised by an attending, and when billing and accountability are based on that, it’s awfully hard to know what a teaching assistant really is,” he said. “We may think we know, but for the record I think it looks quite different.” Dr. Richardson, an ACS Fellow, was recently on the ACGME’s Residency Review Committee for Surgery. It’s possible that the case volume declines a http://www.facs.org http://www.facs.org

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Surgery News - February 2008 Contents IOM Committee Looks Into Safety Of Work Schedules Expertise Can Extend Liver Resectability Report Faults Specialty Hospitals' EDs Meeting Expectations Silver Lining HOD on Health Longer Liver Life?

Surgery News - February 2008

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