Operative Volume in the New Era: A Comparison of Total Resident Operative Volume Pre vs. Post 80-Hour Work Week Restriction Implementation Pamela J. Bruce,

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Presentation transcript:

Operative Volume in the New Era: A Comparison of Total Resident Operative Volume Pre vs. Post 80-Hour Work Week Restriction Implementation Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D. Department of Surgery, The University of Kansas School of Medicine-Wichita Wichita, Kansas

ACGME 2003 Duty Hour Restrictions In-house call no more than every third night One day off per week (averaged over 4 weeks) 24-hour limit (6-hour extension) 10 hours off between shifts <80 work week average

Impact on operative experience Jarman 2004-projected losses of cases Mendoza % reductions predicted by general surgery program directors

Studies Showing Stable Operative Volume Bland no difference in total or chief resident volume Ferguson no change in total operative volume and an increase in chief resident operative volume Schneider 2007-increase in operative volume totals, especially for PGY1&2’s

Studies Showing Negative Impact on Operative Volume Carlin et al significant decrease in operative volume for PGY1, 2, and 4 residents and a decrease in first assist and teaching assist volume Damadi et al overall decrease in both chief and total operative cases Kairys % of residents at risk for not meeting the 750 total case requirement

No previous published study has evaluated operative volume of general surgery residents who completed their entire residency after implementation of work-hour restrictions

Study Objective Determine the impact of the duty hour restrictions (DHR) on general surgery resident operative volume in a general surgery residency program over the course of an entire “DHR” residency

Methods IRB-approved retrospective review Final operative logs of graduated general surgery residents University of Kansas-Wichita -6 residents per year Control group:2001, 2002, 2003 Study group: 2008, ACGME Defined Categories Operative Volumes Non-operative trauma excluded, leaving 18 categories for comparison

Results Operative volumes in 12/18 defined categories were not significantly affected Operative volume in 1/ 18 defined categories (Laparoscopic- Basic) was positively affected Operative volumes in 4/18 defined categories were negatively affected Head/Neck Trauma Thoracic Plastics

Results Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D. Department of Surgery, The University of Kansas School of Medicine-Wichita Wichita, Kansas Before Duty Hour RestrictionAfter Duty Hour Restrictions 2001, 2002, , 2009 Number of Chief ResidentsMinimum RRC Requirements1712P Value Head and Neck * Skin/ Soft Tissue/ Breast Alimentary Tract Abdomen Liver Pancreas Vascular Endocrine Trauma- Operative * Trauma- Non operative Thoracic * Pediatrics Plastics * Endoscopy Laparoscopic- Basic * Laparoscopic- Complex Teaching Cases TOTAL CHIEF CASES TOTAL MAJOR CASES

Results Program changes made to accommodate DHR Night float system PGY3 and PGY1 residents Trauma service changes Cessation of resident coverage at 1 of the 2 level I trauma centers in the community with care provided subsequently by attendings and physician extenders Team concept of trauma coverage with two teams (PGY 2/4, PGY2/5) covering alternating 24 hour periods for 2 month rotations

Discussion Trauma-number of cases decreased by 52% (26 to 13) Deletion of resident coverage at one Level I Trauma Center, substantially decreasing the amount of trauma call taken by residents over the course of the training program Increasing role of non-operative management for the care of trauma patients

Discussion Head/Neck – number of cases decreased by 16% (79 to 66) Majority of cases recorded in this category were tracheostomies of which the majority are performed on the trauma rotation

Discussion Thoracic - number of cases decreased by 28% (45 to 32) Decrease in number of months on the cardiothoracic rotation from 6 to 2 Migration of cases to a specialty heart hospital

Discussion Plastics - number of cases decreased by 31% (20 to 13) No major change in the educational structure of the plastic surgery experience Decrease may be a factor of an anomaly of interest in plastic surgery in the control group Migration of cases to outpatient facilities

Discussion Limitations Single institutional study of case volume involving a limited number of residents Operative volumes and duty hours are self-reported Confounding factors affecting case totals other than duty hours Defined categories do not fully reflect complexity of operative experience

Conclusions Resident operative volume at our institution’s general surgery residency program has been largely unaffected by implementation of the 80-hour work week Residencies in general surgery can be structured in a manner to allow for compliance with duty hour regulations while maintaining the required operative volume as outlined by the ACGME defined categories