Tag Archives: Residents

Resident Work Hour Restrictions And Neurotrauma Complications

In the US, resident work hour restrictions went into effect in 2003, limiting the total number of hours worked per week and the number of consecutive hours without a break. The idea was that fatigue caused errors, which translates into patient complications or worse. Has this panned out? A number of previous publications have found no change; only a few have shown some benefit.

Researchers at Massachusetts General Hospital decided to apply the acid test to this theory. They selected a group of patients who were critically ill and challenging to care for, taken care of by a group of residents who had long work hours and were involved in long operative cases. The AHRQ National Inpatient Sampling Database was studied, comparing the outcomes of neurotrauma patients before and after work hours were initiated and in teaching and non-teaching centers.

A huge number of records were analyzed (40,000 before work hours restrictions, 67,000 after). The findings were intriguing:

  • The overall complication rate was the same before and after restrictions (1.2%)
  • The complication rate was 25% higher in teaching hospitals after restrictions took effect. It appears that this also correlated with higher hospital charges after restrictions.
  • Logistic regression was used to figure out whether this difference was from duty hours or just from the involvement of residents in care. Only duty hours were significant in this analysis.
  • If injury severity was included in the analysis, there were no differences in complications at all
  • There were no differences in mortality rates between any of the groups

Bottom line: Yes, fatigue is bad (see my previous posts below). But here is another (correlation) study that doesn’t bear out the original reasons to restrict resident work hours. In actuality, complications and charges increased after the restrictions went into effect. It is possible that the checks and balances in the system were effective in protecting patients from adverse outcomes. Could the changes in this study be due to staffing changes to meet the restrictions, which results in chronic understaffing which undercuts those checks and balances? Studies of this type can’t tell us that. And unfortunately, restrictions in the US are not going to go away, they’ll probably get worse.

Related posts:

Reference: Higher Complications and No Improvement in Mortality in the ACGME Resident Duty-Hour Restriction Era: An Analysis of More Than 107?000 Neurosurgical Trauma Patients in the Nationwide Inpatient Sample Database. Neurosurgery 70(6):1369-1382, 2012.

Teaching the Trauma Team

Teaching hospitals have extra responsibilities when constructing their trauma activation team. They are typically charged with educating trainees from a variety of disciplines, including residents, medical students, and students from other disciplines (EMT, PA, NP). The activation process must not only provide rapid and high quality trauma care, it must also teach these students how to provide that care.

Residents can be integrated into the typical physician roles on the team: airway and primary examiner. To integrate more trainees, these roles can be split further. For example, the examiner’s role can be split into a primary examiner and a secondary examiner with separate, lesser responsibilities. PAs and NPs can be integrated into these roles as well.

One of the most important “additions” to the team that allows education of senior level residents is the Team Leader. This role allows the trainee to learn how to direct the overall resuscitation and allows them to practice making management decisions on the fly. Typically, the Team Leader does not actually touch the patient, allowing the other examining physicians to do this and learn their specific roles. Each role can be assigned to an appropriate level resident, so that they move to higher levels as they progress through their training program.

Here is a template for a trauma team that allows four trainees (yellow balloons) to participate. One faculty members supervises all of them.

At our Trauma Center, we have these four trainees plus another Emergency Medicine resident who performs the FAST exam, if indicated. Two faculty members participate, one trauma surgeon and one Emergency Medicine faculty. Our total team size is 12, so it must be well-coordinated in order to avoid chaos.

Medical and paramedic students are usually confined to the periphery to take notes (H&P) or just observe.

Please leave your comments describing the composition of your team and what makes it run well.

Tomorrow: qualifications of your trauma team personnel