Resident duty-hour restrictions effect on neurosurgical patients uncertain
MedWire News: Restrictions to resident duty hours have not had the hoped-for positive effect on the outcomes of neurosurgical trauma patients, shows research.
The researchers found that patient mortality in teaching hospitals did not decrease after implementation of the measures from the Accreditation Council for Graduate Medical Education (ACGME) in 2003, relative to rates in nonteaching hospitals, which were not subject to the measures.
There was also a rise in complications in teaching hospitals, although this was coincident with an increase in the number of hospital admissions for neurosurgical trauma.
Brian Hoh (University of Florida, Gainesville, USA) and colleagues chose to study neurosurgical trauma patients because this is one of the most critically ill, highest-risk groups of patients, likely to require emergency procedures off hours or at night. Neurosurgical patients are also thought to be particularly vulnerable to transfer and handoff errors, because of the need for continuity of care to detect subtle neurologic changes.
Using the US Nationwide Inpatient Sample (NIS) database, the team identified a total of 107,006 neurotrauma admissions to teaching hospitals and 115,604 to nonteaching hospital in the periods 1999-2002 (before the duty-hour restrictions) and 2005-2008 (with restrictions).
In teaching hospitals, mortality appeared higher after the implementation of duty-hour restrictions, at 3.17% during 2005-2008 compared with 2.75% in the earlier time period. However, this was not significant after accounting for multiple patient variables, including age, gender, and income; and hospital factors, such as location, bed size, and volume.
Nonteaching hospitals had no evidence of a change in patient mortality between the two time periods.
The complication rate in teaching hospitals was 1.23% in both time periods. But after accounting for confounders, there was a 1.23-fold increase in the rate of complications during the time period with duty-hour restrictions relative to the earlier period. This effect was not seen in nonteaching hospitals.
Hoh et al observe that there was an increase in neurosurgical trauma admissions between the two studied time periods, and that this was weighted toward teaching hospitals, which experienced a 72% rise in admissions, compared with a 38% rise in nonteaching hospitals.
"Unfortunately, the NIS database does not contain data on the number of residents or number of residents per trauma hospitalization," they write in Neurosurgery.
"We suspect that the significant increase in trauma hospitalizations seen over time was not accompanied by an increase in resident workforce, so with restricted resident duty hours, there is now reduced manpower taking care of significantly more patients, leading to higher (not lower) risk of complications and mortality."
The team concludes: "It is possible that the increase in complications seen in teaching hospitals is due to an understaffed resident workforce with less time to care for an increasing patient population."
By Eleanor McDermid