III. Affect of the 2011 duty hour regulations on the source of admission

Harborview Medical Center

2010-2011 2011-2012

2011-2012 primary team 2011-2012 Night Medicine

University of Washington Medical Center

2010-2011 2011-2012

2011-2012 primary team 2011-2012 Night Medicine

2010-2011 2011-2012

Mean CI Mean CI P-valueHMC #New admits per day 11.4 0.4 11.4 0.6

#New admits per day by primary team 11.1 0.5 7.9 0.5 5.0E-15#New admits per day by night medicine 0.2 0.2 3.5 0.4 3.2E-30%Admits by primary team 98.0 3.8 69.1 2.9 1.7E-35

UWMC #New admits per day 4.7 0.5 5.5 0.5#New admits per day by primary team 4.5 0.5 3.1 0.3 6.8E-6#New admits per day by night medicine 0.2 0.2 2.4 0.4 2.2E-19%Admits by primary team 96.2 3.0 57.0 5.9 5.5E-20

FLOAT #New admits per day 0.9 0.4#New admits on night shift 0.2 0.1#New admits on day shift 0.7 0.3

impact of the 2011 duty hours on the inpatient internal medicine resident experience

Samuel Hundert MD*, Dominic Reilly MD§, Andrew White MD§

*Internal Medicine Residency And §Division of General Internal Medicine, University of Washington, Seattle WA

Background

Effective July 1, 2011 the ACGME issued new resident duty hour regulations limiting consecutive work hours: -interns: no more than 16 hours -residents: no more than 28 hours Concerns about the change: -ensuring adequate volume of patient care -potential to negatively impact preparedness for unsupervised practice -more frequent handoffs introduce safety risks

Objective

To retrospectively examine changes in the number, source, and timing of new inpatient admissions by internal medicine PGY-1 residents in the University of Washington residency program before and after implementation of the 2011 duty hour regulations

To review average daily census for PGY-1 internal medicine residents on general inpatient internal medicine rotations prior to and following the 2011 duty hour regulations

Results

I. Affect of the 2011 duty hour regulations on number of patient admissions

Discussion

I. Average number of new admissions

Total number of patients admitted to housestaff at UWMC and HMC per day is unchanged Post 2011 duty hour regulations, day medicine interns admit fewer patients -decreased admitting time -Two 8-10 hour blocks post-2011 vs. one 24 hour block pre-2011 -shared admitting time -2 teams admitting simultaneously -teams rarely reach maximum (cap) -UWMC: max 5, actual 3.1 -HMC: max 10, actual 7.9 -schedules are not equivalent -HMC: pre: 7-9 max per cycle post: 5 max per cycle -UWMC: pre: 7 max per cycle post: 5 max per cycle

Number of inpatient general medicine admissions per year per intern is similar with inclusion of night medicine

*calculated values based on results and team structure, excludes VA rotation

II. Average Team Census

On a daily basis, current PGY-1 residents care for a similar number of patients as interns prior to 2011

III. Distribution of Admissions

Currently day medicine residents admit a higher proportion of patients as ICU transfers and from clinic, fewer from ED -ICU/clinic patients have been seen by an IM attending prior to admission -night medicine admits almost exclusively from the ED

Conclusion

It is reassuring that the number of new admissions has remained constant.

The current system, although involving more transitions in care, may prepare trainees to the extent that this model reflects handoff patterns in community practice

Ideally the decrease in daytime admissions will allow residents to more thoughtfully approach their patient encounters and attend conferences

Night Medicine is taking on a much more important role In resident training

II. Average Daily Census

2010-2011 2011-2012

HMC 6.5 6.4

UMWC 7.4 7.9Methods

Population: Patients cared for by University of Washington PGY-1 residents on general inpatient and night medicine rotations

Setting: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC).

Data source: Database records from a shared electronic medical record (Cerner PowerChart) with signout software (CORES) -Review Method: Chart review for abstraction of administrative data -Chart selection: All admission notes from a random sample of 56 days in academic year 2010-2011 and 2011-2012 -Data abstracted: the admitting physician and source (ED, ICU transfer, hospital transfer, team transfer, clinic admit), cross referenced against resident schedules to identify the admitting team -Endpoints: Number of new admissions handled by the primary/night team each day, average team census at midnight

Institutional Review Board Approval was obtained from the University of Washington Human Subjects Division

Statistical Analysis performed with assistance of the UW Biostatistics Graduate Student Consulting Program

Blue represents academic year 2010-2011 and Red represents academic year 2011-2012. Each dot represents the number of new admissions to the hospital (y-axis) on the day of interest (x-axis). The scatter plots above shows the total number of new medicine admissions per day to the hospital (regardless of admitting team). The scatter plots below shows the number of new admissions per day done by the primary inpatient resident medicine service.

Day Of Interest Day Of Interest

The above pie charts demonstrate how the source of admissions to the primary medicine team has changed as a results of the new duty hour regulations. Overall a similar number of patients are being admitted from each respective source, however, day medicine residents are now admitting fewer ED patients and more patients as ICU transfers and from clinic

Average daily census per intern at each institution has remained constant following implementation of the 2011 duty hour regulations

Average number of new admissions per day to each hospital and the number/percentage admitted by the primary medicine service prior to and following the 2011 duty hour regulations

Day Of Interest Day Of Interest

Harborview Medical Center

Harborview Medical Center

UW Medical Center

UW Medical Center

HMC UWMC Float Total2010-2011 31.2 31.6 9.1 71.92011-2012 22.0 22.0 33.3 77.3