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#Grand Rounds

Have the New Resident Work Hours Rules Improved Patient Safety?

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BACKGROUND AND PURPOSE:

  • Silber et al. (New England Journal of Medicine, 2019) compared the standard resident work hours vs flexible hours and their impact on patient safety

METHODS:

  • Cluster-randomized non-inferiority trial
    • 63 internal-medicine residency programs (2015-2016 academic year)
  • Programs were randomly assigned to either
    • Standard duty hours as defined by the Accreditation Council for Graduate Medical Education (ACGME)
    • Flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts
  • Primary outcome: Change in unadjusted 30-day mortality from the year before the trial and the trial year as determined from Medicare claims
  • Secondary outcomes
    • 7-day and 30-day rates of hospital readmission or death | Patient safety indicators (AHRQ) | Prolonged length of hospital stay | Medicare Payments
  • Statistical Analysis
    • Noninferiority margin was set at 1% (mortality would not be more than 1% worse in the flexible program compared to the standard hours by program)

RESULTS:

  • 32 flexible programs with 121,951 admissions | 31 standard programs with 142,634 admissions
  • The change in 30-day mortality among patients in the flexible programs was noninferior to that among patients in the standard programs
  • There were also no statistical differences in changes between the flexible programs and standard programs in
    • Unadjusted rate of readmission at 7 days
    • Patient safety indicators
    • Medicare payments
  • The noninferiority criterion was not met for
    • 30-day readmissions
    • Prolonged length of hospital stay

CONCLUSION:

  • ‘Flexible resident schedules did not result in harm to patients
    • Authors note that the flexible programs did not consistently use extended shifts
    • Ability of program directors to use extended shifts at their discretion was a feature to promote ‘pragmatic’ study design
  • Another companion study showed no more chronic sleep loss or sleepiness among interns in flexible programs than those in standard programs (See ‘Learn More – Primary Sources’ below)
  • The authors state that

…allowing program directors the discretion to make their own schedules without continuous duty-hour limits did not result in worse patient outcomes.

Learn More – Primary Sources:

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine

Eyes Wide Open — Examining the Data on Duty-Hour Reform

Now You Can Get ObG Clinical Research Summaries Direct to Your Phone

Learn More  »

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Related ObG Topics:

Need for Paid Parental Leave and Resident Physician Training Requirements – Often at Odds
Is Joint Commission Accreditation Associated with Better Patient Outcomes?
Do Pay for Performance Incentives Enhance Hospital Performance?

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