Kyla Terhune, MD, Lesly Dossett, MD, MPHVanderbilt University Medical Center

At Vanderbilt University Medical Center: Appears to be an increase in “demand”

▪ Aging, sicker, more complex patients

No concomitant increase in residents

July 2003: ACGME restrictions further decrease in supply

Scenario 1: Residents are working fewer hours… Therefore see fewer patients… Therefore “work” less hard and learn less…

Scenario 2: Patient load and acuity have increased… Even though residents are working fewer hours… They are busier and working harder during that time.

PRO Safety unchanged

or improved Morale better Education improved No change:

operative cases No change:

mortality

CON Safety declined Attrition higher Quality of med

student education has declined

Significant decline in op cases (assists)

Higher complications

UT Southwestern (Frankel, H.L., et al. J Trauma, 2006.):

2003: reallocated residents in SICU to comply w 80 hrs

2004: SICU readmission rates (RR) doubled Attributed increased RR to lack of continuity Targeted intervention to reduce RR

UMDNJ (Gordon, C.R., et al., Am Surg, 2006)

Surveyed programs in order to determine strategies Found 37% supplement with non-GS housestaff

Baylor: Trauma ICU Morrison, C.A., M.M. Wyatt, and M.M. Carrick, J Surg Res, 2009

National Trauma Data Bank (NTDB) 2001-02 (pre) and 2004-05 (post) Mortality decreased significantly

Admissions to surgical ICUs (BICU, TICU, SICU) at VUMC have increased.

Patient acuity (as measured by hospital days and ventilator days) has increased.

Resident complement and work hours in these units have decreased.

How do changes in hospital acuity and volume compare to…

resident numbers and work hours in the surgical critical care unit?

Remember vinyl records?

33 1/3 RPM: pre 80-hour workweek

78 RPM: post 80-hour workweek

My interpretation… Sinatra vs. Chipmunks

Admissions TICU, BICU, SICU Total initial admissions per month

Acuity ICU-days per patient Hospital-days per patient Ventilator-days per patient (billing charge per 24 h)

Other measures of acuity (APACHE II)

Numbers General Surgery residents Supplemental residents from other services:

▪ ED residents: TICU▪ Anesthesia: SICU▪ OB/Gyn: SICU

Hours

1998-2003 “We worked 110-120 hours per week.” 36 hour call (6 am to 6 pm following day) Non-call: 6 am to 6 pm Did not assume days off, given unit months, acuity Call schedule calculated by number of residents at

that level▪ 3 interns: q3▪ 2 seniors on trauma: q2

Q2 week: 126 hours

Q3 week: 112 hours

Sun Mon Tues Wed Thur Fri Sat

2003-2008 Hours data from department Missing data (291/3718, 7.8%)

▪ 80 hours (maximum)

Opted for 80: ▪ worked “against” our hypothesis▪ Maximum they would be “allowed” to work

ICU Admissions ICU days Hospital Days Ventilator Days

“Resident Days” (hours/24 hrs/day) Comparable to total hours

R2 = 0.4432

150.0

200.0

250.0

300.0

350.0

400.0

450.0

Jul-

98

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99

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00

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Nu

mb

er

of

Ad

mis

sio

ns

R2 = 0.7101

0.0

500.0

1000.0

1500.0

2000.0

2500.0Ju

l-98

Jul-9

9

Jul-0

0

Jul-0

1

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ICU

Day

s

Reflect changes in practice

Increase in tracheostomies Decreased sedation Spontaneous breathing trials “Wake up and breathe”

R2 = 0.9645

0.0

2.0

4.0

6.0

8.0

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20.0Ju

l-9

8

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Nu

mb

er

of

Re

sid

en

ts

Residents were pulled from other services Pulled residents from other hospitals (loss of primarily operative services)

Initiation of closed units in SICU Dedicated ICU team

R2 = 0.7124

R2 = 0.6056

100

120

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260Ju

l-9

8

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99

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00

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t-D

ay

s

Hours divided by 24 hrs/day Unit similar to Hospital Days or ICU Days

Total resident days have increased Increased number of residents in ICUs But we have “maxed” out our supply

0.50.70.91.11.31.51.71.92.12.32.5

Jul-

98

Jul-

99

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00

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Months

ICU

ad

mis

sio

n:

res

ide

nt-

da

ys

Comparing post to pre More ICU admissions per resident days More new patients and higher census

Slope not increasing Proper supplementation of numbers of

residents Numbers are maxed out though…

2.0

4.0

6.0

8.0

10.0

12.0

14.0Ju

l-9

8

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99

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ICU

da

ys

: R

es

ide

nt

da

ys

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0Ju

l-9

8

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99

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00

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Ve

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s:

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s

Residents may be caring for fewer and fewer patients on ventilators

May reflect change in practice

However, still greater ratio in 2008 than in 1998.

1998-99 2007-08

Admissions: RDs 1.44 1.68

ICU Days: RDs 6.14 9.38

Hosp Days: RDs 11.49 13.98

Vent Days: RDs 2.40 3.78

Are the hours correct? Carpenter, R.O., et al., Am J Surg, 2006.

Adjustments prior to initiation of 2003 Physician extenders Moonlighters

ICU admissions have increased. ICU length of stay has increased. There is an overall increase in volume and acuity.

Redistribution of residents to ICU has been appropriate. But volume is increasing. Resident capacity is maxed out.

The acuity and volume of work in 2008 during working hours is greater than in 1998.

Critical Care Tower: November 2009 Need more residents in ICUs? Critical care track? Certainly cannot afford to work fewer hours.

Patient safety Maxed out physician extenders

Educational impact: Removal from operative services? Educational programs in the ICU

Stephanie Rowe Allison Watts Margaret Tarpley Kelly Dilahuay Linnea Hauge, PhD Kim Schenarts, PhD John Tarpley, MD