Reduced resident work hours in the SICU: The nurses’ perspective Zara Cooper, MD, MSc Ian Shempp, BS Selwyn O. Rogers, MD,MPH Department of Surgery Brigham and Women’s Hospital Boston, MA

SICU was the last holdout Average every 3rd night call 30 hour call days One day off per week 10 hours between shifts

Objective: Mitigate adverse events further by improving resident sleep hygiene Solution: –56 hour week –3-4 shifts per week –Shifts no more than 16 hrs long –One day off per week –10 hours between shifts SICU Study

800-bed tertiary urban referral center 3 10-bed surgical ICUs: General surgery Burn/Trauma Thoracic surgery ICU SICU Study

Staffing changes for 56-hour work week Introduced physician extenders –2 NPs and 2 PAs to work in general surgical and trauma ICU Added a 4th anesthesia resident to Thoracic SICU Added one additional fellow to each ICU

ICU staffing Before One attending physician from multi-disciplinary pool One surgical or anesthesia ICU fellow 3 residents from surgery, anesthesia or emergency medicine After One attending physician from multi-disciplinary pool TWO surgical or anesthesia ICU fellows 3 residents from surgery, anesthesia or emergency medicine TWO physician extenders or a 4th resident

Academic changes to SICUs After Attending walk rounds twice a day at 8 a.m. and 5 p.m. Didactics at 7 a.m. before morning rounds Before Attending walk rounds once at 7 a.m. Didactics at 11 a.m.

Questions Were there fewer adverse events? Did it effect resident education? Were Physician Extenders and Residents interchangeable?

The ICU nurse on the frontline Directly effected by schedule and staffing changes Experienced nurses teach inexperienced residents a great deal about patient care

The survey Objective: To learn how nurses felt about reduced work hours –Adverse events –Resident as point person –Resident knowledge –Physician extenders to fill the gap

The survey Design: –15 questions: Likert-type and open-ended –Structure and clarity validated with focus groups –IRB approved – No Incentive Survey distributed 3 months after change

The survey Distribution: –Electronic distribution via to permanent nursing staff on in 3 ICUs –Link to Survey Monkey –Anonymous with unique identifier to contact non responders (NR) –Partial responders and non-responders contacted by research staff weekly for 10 weeks

Survey results Response rate 59% –99% primarily SICU nurses –80% female –58% with more than 10 years as ICU nurse –66% from the day shift; 6% from nights There were no statistical differences between R and NR (p=0.08 )

Survey results No statistical differences in responses by shift Nurses with more than 5 years experience were more likely to approach attending staff to deal with families (p=0.003)

Role of the attending in the ICU Respondents went to attending staff more frequently with complex questions Reported more interactions with attending staff –May reduce resident opportunity for complex problem-solving –May compromise resident role and authority with respect to patient care

Comments about residents: “Continuity is a concern.” “…residents don’t have enough time to get a good handle on the patients.” “…residents are completely out of the loop on my unit. I go to the fellow or attending for almost everything.” ‘…residents know MORE now because there are {fewer} residents to dilute their responsibility.”

Comments about physician extenders “I find the PAs to be exceptional…however, I still go to residents and fellows because I do not feel confident in their decisions.” “NP has broader base and often can better understand issues relating to nursing care.” “For the most part I feel more comfortable with the residents.”

Study Limitations Premise: Nurse/resident interactions are an important component of resident education in the SICU –Little data about the role of ICU nurses in resident education –May just be our observation and may not be applicable in all SICUs

Study Limitations Setting –One 800 bed tertiary medical center –Just 3 ICUs and 133 nurses Hours: –Highly complex schedule and residents worked most nights and weekends –The work hours changes were not implemented with nurse-resident interactions in mind –Work hours changes were not designed to improve resident education

Study Limitations Survey –59% response rate –Did not have an objective measure of resident activity to validate survey results –Did not have data from before the changes –Not all shifts were equally represented –Was 3 months enough time for nurses to feel comfortable with the new schedule?

Conclusions Changes in resident work hours effect nurse- resident interactions Physician extenders are not interchangeable with residents from a nursing perspective Increased attending presence may change the types of clinical problems presented to residents

Some important questions How do resident/nurse interactions effect resident education in the SICU? How do physician extenders in the SICU effect these interactions and resident experience? Does a decrease in the hours residents spend in the ICU, undermine their relevance in clinical care?