Quality Improvement
In ICUs, 24-, 16-, and 12-hour overnight resident duty schedules did not differ for patient adverse events Clinical impact ratings:
多多多多多多夞
Parshuram CS, Amaral AC, Ferguson ND, et al; Canadian Critical Care Trials Group. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ. 2015;187:321-9.
多多多多多多夞
Question
Conclusion
In intensive care units (ICUs), do 24-, 16-, and 12-hour overnight resident duty schedules differ for patient adverse events (AEs)?
In intensive care units, 24-, 16-, and 12-hour overnight resident duty schedules did not differ for patient adverse events.
Methods Design: Cluster-randomized controlled trial with 6 clusters (3 resident rotations in each of 2 ICUs). ClinicalTrials.gov NCT00679809. In 1 ICU, the first resident rotation was allocated to the 24-hour schedule, and the next 2 rotations were randomized to the 12- or 16-hour schedule; in the other ICU, all 3 resident rotations were randomized. Allocation: Unclear allocation concealment. Blinding: Blinded* (adverse event adjudicators). Follow-up period: First of hospital discharge or 2 weeks after transfer from ICU for patients; 2 months for residents. Setting: 2 academic medical–surgical ICUs in Toronto, Ontario, Canada. Participants: 807 adults (median age 61 y, 971 ICU admissions, 5894 patient-d in ICU) who were admitted to a participating ICU, and 47 residents (66% 25 to 30 y of age, 49% internal medicine trainees) who were trained in an accredited program and had overnight duty supervision from on- or off-site fellows or intensivists. Intervention: 2-month resident rotations, with overnight duty schedules of 24 (2 rotations, 15 residents, 311 ICU admissions), 16 (2 rotations, 15 residents, 293 ICU admissions), or 12 hours (2 rotations, 17 residents, 367 ICU admissions). Each rotation included ≥ 5 residents and had ≤ 7 overnight shifts and 2 free weekends every 28 days. Outcomes: Primary patient outcome was AEs (unplanned injury with morbidity or disability at discharge, needing treatment, or prolonging hospital stay, and resulting from medical care in the ICU). Other outcomes included preventable patient AEs, ICU mortality, and resident burnout (Maslach Burnout Inventory [MBI]). {1800 patient-days per schedule}† were needed to detect a relative rate difference ≥ 0.26 for patient AEs (80% power). Participant follow-up: 100% for patients; 87% for MBI in consenting residents.
*See Glossary. †Information provided by the author. Sources of funding: Canadian Institutes of Health Research; Centre for Quality Improvement and Patient Safety of the University of Toronto; Research Institute at the Hospital for Sick Children. For correspondence: Dr. Christopher S. Parshuram, Hospital for Sick Children, Toronto, ON, Canada. E-mail [email protected].
Commentary Fatigued interns and residents who work long hours are less attentive and more prone to making medical errors (1). Governing bodies in Europe and North America have limited work hours for residents, with the goals of improving patient safety and reducing resident fatigue. Studies in ICUs have shown fewer serious medical errors with reduced work hours for interns (2), as well as increased sleep time and fewer attention failures (3). Paradoxically, reduced work hours can have the unintended consequence of increasing workload since the same amount of clinical work must be done in fewer hours. This has not improved resident education (4) but has increased frequency of hand-offs, which is associated with increased medical errors (5). Novel changes to resident training that decrease workload, not hours, have improved resident satisfaction and increased time for education, without adversely affecting patients (6). Parshuram and colleagues examined the effect of 24-, 16-, and 12-hour ICU shifts on resident well-being, continuity of care, and patient safety. They found no differences between schedules. The trial, however, was underpowered, so true differences may not have been detected. In an era where fewer hours are worked per week, more trials are needed to determine the optimal use of those hours. Randolph J. Lipchik, MD Medical College of Wisconsin Milwaukee, Wisconsin, USA
Main results The main patient outcomes are in the Table. 24-, 16-, and 12-hour duty schedules did not differ for high resident burnout at the end of rotation (MBI depersonalization domain, 46% vs 64% vs 64%, P = 0.7; MBI emotional exhaustion domain, 54% vs 57% vs 57%, P > 0.9; personal accomplishment domain, 54% vs 43% vs 21%, P = 0.2).
Patient adverse events Preventable patient adverse events
Events per 1000 patient-d 24-h schedule
16-h schedule
12-h schedule
81
76
78
0.5
0
3.2
P value
0.7 0.1§
18%
17%
3. Lockley SW, Cronin JW, Evans EE, et al; Harvard Work Hours, Health and Safety Group. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829-37. 4. Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The effects of workhour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165:2601-6. 5. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-7.
Event rates ICU mortality (% ICU admissions)
1. Lockley SW, Barger LK, Ayas NT, et al; Harvard Work Hours, Health and Safety Group. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):7-18. 2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-48.
Effect of 24-h vs 16-h vs 12-h overnight resident duty schedules on patient outcomes in the ICU‡ Outcomes
References
14%
‡ICU = intensive care unit.
0.2
6. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010; 362:1304-11.
§For 24-h vs 12-h duty schedule comparison.
姝 2015 American College of Physicians
JC12
ACP Journal Club
Annals of Internal Medicine
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/934240/ by a University of California San Diego User on 06/26/2017
21 Jul 2015
In ICUs, 24-, 16-, and 12-hour overnight resident duty schedules did not differ for patient adverse events Clinical impact ratings:
多多多多多多夞
Parshuram CS, Amaral AC, Ferguson ND, et al; Canadian Critical Care Trials Group. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ. 2015;187:321-9.
多多多多多多夞
Question
Conclusion
In intensive care units (ICUs), do 24-, 16-, and 12-hour overnight resident duty schedules differ for patient adverse events (AEs)?
In intensive care units, 24-, 16-, and 12-hour overnight resident duty schedules did not differ for patient adverse events.
Methods Design: Cluster-randomized controlled trial with 6 clusters (3 resident rotations in each of 2 ICUs). ClinicalTrials.gov NCT00679809. In 1 ICU, the first resident rotation was allocated to the 24-hour schedule, and the next 2 rotations were randomized to the 12- or 16-hour schedule; in the other ICU, all 3 resident rotations were randomized. Allocation: Unclear allocation concealment. Blinding: Blinded* (adverse event adjudicators). Follow-up period: First of hospital discharge or 2 weeks after transfer from ICU for patients; 2 months for residents. Setting: 2 academic medical–surgical ICUs in Toronto, Ontario, Canada. Participants: 807 adults (median age 61 y, 971 ICU admissions, 5894 patient-d in ICU) who were admitted to a participating ICU, and 47 residents (66% 25 to 30 y of age, 49% internal medicine trainees) who were trained in an accredited program and had overnight duty supervision from on- or off-site fellows or intensivists. Intervention: 2-month resident rotations, with overnight duty schedules of 24 (2 rotations, 15 residents, 311 ICU admissions), 16 (2 rotations, 15 residents, 293 ICU admissions), or 12 hours (2 rotations, 17 residents, 367 ICU admissions). Each rotation included ≥ 5 residents and had ≤ 7 overnight shifts and 2 free weekends every 28 days. Outcomes: Primary patient outcome was AEs (unplanned injury with morbidity or disability at discharge, needing treatment, or prolonging hospital stay, and resulting from medical care in the ICU). Other outcomes included preventable patient AEs, ICU mortality, and resident burnout (Maslach Burnout Inventory [MBI]). {1800 patient-days per schedule}† were needed to detect a relative rate difference ≥ 0.26 for patient AEs (80% power). Participant follow-up: 100% for patients; 87% for MBI in consenting residents.
*See Glossary. †Information provided by the author. Sources of funding: Canadian Institutes of Health Research; Centre for Quality Improvement and Patient Safety of the University of Toronto; Research Institute at the Hospital for Sick Children. For correspondence: Dr. Christopher S. Parshuram, Hospital for Sick Children, Toronto, ON, Canada. E-mail [email protected].
Commentary Fatigued interns and residents who work long hours are less attentive and more prone to making medical errors (1). Governing bodies in Europe and North America have limited work hours for residents, with the goals of improving patient safety and reducing resident fatigue. Studies in ICUs have shown fewer serious medical errors with reduced work hours for interns (2), as well as increased sleep time and fewer attention failures (3). Paradoxically, reduced work hours can have the unintended consequence of increasing workload since the same amount of clinical work must be done in fewer hours. This has not improved resident education (4) but has increased frequency of hand-offs, which is associated with increased medical errors (5). Novel changes to resident training that decrease workload, not hours, have improved resident satisfaction and increased time for education, without adversely affecting patients (6). Parshuram and colleagues examined the effect of 24-, 16-, and 12-hour ICU shifts on resident well-being, continuity of care, and patient safety. They found no differences between schedules. The trial, however, was underpowered, so true differences may not have been detected. In an era where fewer hours are worked per week, more trials are needed to determine the optimal use of those hours. Randolph J. Lipchik, MD Medical College of Wisconsin Milwaukee, Wisconsin, USA
Main results The main patient outcomes are in the Table. 24-, 16-, and 12-hour duty schedules did not differ for high resident burnout at the end of rotation (MBI depersonalization domain, 46% vs 64% vs 64%, P = 0.7; MBI emotional exhaustion domain, 54% vs 57% vs 57%, P > 0.9; personal accomplishment domain, 54% vs 43% vs 21%, P = 0.2).
Patient adverse events Preventable patient adverse events
Events per 1000 patient-d 24-h schedule
16-h schedule
12-h schedule
81
76
78
0.5
0
3.2
P value
0.7 0.1§
18%
17%
3. Lockley SW, Cronin JW, Evans EE, et al; Harvard Work Hours, Health and Safety Group. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829-37. 4. Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The effects of workhour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165:2601-6. 5. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-7.
Event rates ICU mortality (% ICU admissions)
1. Lockley SW, Barger LK, Ayas NT, et al; Harvard Work Hours, Health and Safety Group. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):7-18. 2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-48.
Effect of 24-h vs 16-h vs 12-h overnight resident duty schedules on patient outcomes in the ICU‡ Outcomes
References
14%
‡ICU = intensive care unit.
0.2
6. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010; 362:1304-11.
§For 24-h vs 12-h duty schedule comparison.
姝 2015 American College of Physicians
JC12
ACP Journal Club
Annals of Internal Medicine
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/934240/ by a University of California San Diego User on 06/26/2017
21 Jul 2015
