3 Case Studies: Reducing resident On-Call shifts to ≤ 16 Hours
When the Institute of Medicine released a report last year recommending that on-call shifts be limited to 16 hours,many skeptics argued it couldn’t be done, or that it would come at a cost—more signouts, and less continuity of care.
However, some residency programs have already made the transition to shifts of no more than 14 or 16 hours, with great results. Here are three case studies from Washington State, Ohio, and New York, where programs have redesigned their work hours to fit the evidence that a 16-hour limit is safer for resident physicians and their patients.
Virginia Mason Medical Center, Seattle, WA
Since 2007, Virginia Mason Medical Center has operated a night float system in its Internal Medicine residency program, enabling residents in the ICU to achieve and maintain a maximum shift of 13.5 hours. The internal medicine program is made up of 35 residents – 10 per PGY and an additional 5 preliminary medicine interns.
The key to Virginia Mason’s transition was redesigning the resident rounds. According to Program Director Dr. Alvin Calderon, the redesign focused on two areas: 1) creating an inpatient rounding schedule, and 2) defining what happens in each rounding encounter. For example, each bedside encounter was designed to ensure that the patient’s concerns were talked over, the nurses’ concerns were discussed, and the resident’s learning needs were addressed.This enabled the physicians to use their time efficiently, so that they were not trying to squeeze more work into a shorter amount of time. Dr. Calderon said residents’ active participation and investment in the redesign has been key. “They understand patient-centeredness,” he said. “And it’s not about trying to work less. It’s about doing the right work.”
Summa Health System, Akron, OH
“Really, we just looked at various opportunities to cut the number of hours that residents spent here without reducing the amount of work they were doing or the number of patients they were seeing,” said Dr. David Sweet, Program Director in Internal Medicine at Summa Health System, which runs Akron City Hospital. “So even today on a 16-hour plan, we see more patients than we saw in 2003-2004, and we have the same number of residents that we had at that time.” The program gradually introduced night float, and also addressed continuity of care concerns through a team model.
Residents were enthusiastic about the move away from 30-hour shifts. “We’ve become much better about handing off patients,” said Dr. Jonathan Hlivko, a resident in the program. “I don’t feel like I’m missing out on learning because, even though I go home at 6:30 or 7 pm and the night team comes and takes over, I’m back in to round on those patients the next morning.” Dr. Hlivko and many of his fellow residents said they feel like that they can go home and read about a case, learn a little bit more, and come back in the morning armed with fresh information.
The internal medicine program at Summa Health System was accepted into and recognized by the ACGME’s Educational Innovations Project (EIP) for its creative approach to restructuring work hours.
St. Luke’s-Roosevelt Hospital Center, New York, NY
For several years, St. Luke’s-Roosevelt Hospital’s internal medicine residents have worked a maximum shift of 14 hours, and that’s only in very intensive rotations like ICU or the “medical consult” done by third-years.
“Nothing is longer than 14 hours,” said Dr. Farbod Raiszadeh , a NY CIR Vice President and recent alumnus of St. Luke’s internal medicine program. “There may be exceptional cases where people stay longer, but the attendings and program directors are committed to getting people out on time,” Dr. Raiszadeh said.
He credits Dr. Ethan Fried, Medicine program director and head of GME, with making the change. “Without Dr. Fried, these changes wouldn’t have happened,” Dr. Raiszadeh said.
Like the other programs, introducing a night float at St. Luke’s was necessary in order to put an end to 24-hour call.
St. Luke’s-Roosevelt also continues to address the challenges of improving signouts.Dr. Fried has developed a template to standardize the signout and make sure certain elements are included, Dr. Raiszadeh said. “The second step he took was he wanted to make sure signouts are done face to face, between residents who are in a calm environment, not rushed, and without interruptions.”