Patient Care Improves when Medical Residents Work Fewer Hours
New Haven, Conn. — When medical residents work shorter hours, fewer patients are transferred to intensive care and there are not as many interventions by pharmacists to avoid errors in medication, according to a Yale School of Medicine study in Annals of Internal Medicine.
In addition, when residents’ work schedules are limited to 80 hours per week more patients are discharged to their homes or rehabilitation centers instead of facilities such as nursing homes, the researchers found.
“What might have helped is reduced fatigue and clinical involvement by more senior physicians to compensate for frequent turnover of house staff,” said Leora Horwitz, M.D., postdoctoral fellow in internal medicine and lead author of the study. “We found no evidence of adverse unintended consequences after the institution of work-hour regulation.”
The Accreditation Council for Graduate Medical Education (ACGME) implemented work-hour regulations in July 2003 in hospitals across the country. Following the institution of these regulations, residents were no longer allowed to work more than 80 hours a week. The rules were intended to reduce errors caused by fatigue. However, one concern was that patient care would be transferred more often, increasing the possibility of mistakes.
Horwitz and her colleagues compared outcomes for patients under the care of house staff, or a teaching service, and patients cared for by a non-teaching service. They looked at data for patients discharged from July 1, 2002, to June 30, 2004. This included one year before and one year after the work-hour regulations were instituted.
In addition to the three outcomes that improved, the researchers measured length of stay, rates of 30-day readmission, in-hospital mortality, and drug-drug interactions.
Before the new work-hour rules, a resident and one intern remained in the hospital overnight on call every fourth day, during which they cared for their own patients and briefly for those of one other team. Over four weekdays, a patient was typically subject to eight transfers of care.
Under the new rules, residents no longer stay overnight and are replaced by “nocturnalists,” non-resident physicians who do the work of the night resident. The reorganization adds one extra transfer of patient care every four days and increases discontinuity because of the large number of rotating nocturnalists, a new resident day float and the absence of the primary resident on call nights.
“Overall, we found that a major reorganization of patient care to reduce resident work hours was implemented without evidence of harm to patients,” Horwitz said.
Co-authors included Mikhail Kosiborod, M.D., Zhenqiu Lin, and Harlan Krumholz, M.D. The Department of Veterans Affairs and the Robert Wood Johnson Foundation supported the research.
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