Resident Work Hour Restrictions Improve Patient Care

The holographic doctor from Star Trek. He never got tired. He never made mistakes. All he would do is get saucy when too many people were bothering him. If only all of us could be like that...(tear)

Anyway, unfortunately we aren't all like him, and to address the issue the Accreditation Council for Graduate Medical Education -- the body responsible for certifying medical residencies in the US -- implemented in 2003 work rules to limit the number of hours residents can work. (The details of the rules can be found here.) Among other things, the rules limit the number of hours that a resident can work to 80 hours a week, and they insist that after 24 hours of "in-house call" (read: the night shift) they cannot accept new patients. (They also must have 24 hours of continuous off time every week.)

Partly this system was employed to reduce medical errors. Many residents were complaining -- and they had the evidence on their side -- that no human being can be expected to work error-free for 120 hours a week. Later studies into the new hours limits have shown that medical errors decrease under the new system.

One criticism of the new system is that because you have to increase the level of turn-over of residents during the week, you are passing patients between doctors a lot.

Let me just explain how this works. Say you are not on-call that day (meaning you are not working the night shift). At the end of the day, you sit down with the person who is working the night shift, and you list all the patients you have and what is wrong with them. You note any lab results that you expect during the evening and if there is something in particular they should watch for. You can get pretty good at this process, so after some practice it doesn't take much time. However, it is possible to make mistakes. Say the patient's blood work needs to be continuously monitored, and this doesn't get conveyed to the night staff. That patient could decompensate overnight and no one would be the wiser.

Thus, one concern about the new system was that the increases in turn-over might cause a paradoxical decline in the quality of patient care because patients were getting passed off more than on the old system.

A paper just published in the Annals of Internal Medicine shows that rather than hurting the quality of care, the new hours rules actually improve it.

Horwitz et al. compared the quality of care through a variety of measures in a hospital that had adopted the new work rules to a non-teaching hospital. The measures that they use to assess quality of care were...

• ICU utilization -- how many patients end up in the ICU
• discharge to home or long-term care facility -- whether you could send elderly patients home or whether they had to go to a nursing facility
• pharmacist intervention -- whether the pharmacist had to correct drug prescription errors made by the doctors
• length of stay -- total time in-hospital
• 30-day readmission rate -- whether if you send them home, they come right back
• drug-drug interaction -- number of times incompatible drugs are mixed
• in-hospital deaths

What they found is that for at least some of those measures the new work hour provisions improved the quality of care:

We compared outcomes in patients cared for by housestaff and those cared for by a nonteaching hospitalist service. We found that, relative to what would have been expected without the regulation, work-hour limits were associated with statistically significant improvements in 3 outcomes: ICU stay (decrease, 2%), discharge to home or rehabilitation versus elsewhere (increase, 5%), and pharmacist interventions to prevent errors (decrease, 1.9 interventions per 100 patient-days). We did not find statistically significant differences in length of stay, 30-day readmission rate to the study hospital, drug-drug interactions, or in-hospital death. Overall, the regulations were associated with neutral or positive changes in all of the outcomes we studied.

All good, right? From these results, the authors conclude that the new work restrictions improve the quality of care, and -- with respect to these results and others I have read -- I mostly agree with them.

However, I would like to add one caveat. This study compared patients on a teaching service with the new work rules to those on a non-teaching service. They did not compare the new work rules to the old work rules both on teaching services. This is an important caveat because the outcomes at teaching hospitals are usually better than at non-teaching hospitals (although it depends somewhat on which teaching hospitals you are referring to). Ideally, you would like to perform the direct comparison, but to my knowledge that study has not been done with respect to health care outcomes.

Thus while we can say that this study and others like it suggest improvements in outcome under the new work rules, it does not prove them definitively. Still, I think it is an important step in showing why it is a good idea for everyone not to over work your residents.

Hat-tip: Eurekalert.