1. Supporting the Challenges of Surgical Resident Training in the Era of Strict Duty-Hour Compliance using an Integrated Advanced Practitioner Model Randy Edwards, MD Department of Surgery Hartford Hospital University of Connecticut

2. Integrated AP Model December 16 th, 2009 ACGME Letter Two RRC anonymous survey citations Citation #1 – Continuous onsite duty 21% of residents revealed they had worked more than 30 consecutive hours – staying late or coming in early Citation #2 – Adequate time for rest 29% of residents revealed they had not received at least 10 hours off duty between shifts – rounds were consistently running late

3. Integrated AP Model Hartford Hospital General Surgery Services Red, Blue, and Green 3-4 residents per service with 1 AP Daily Census – typically 25-30 patients Consults 18-24 per day Late running OR cases (after 5pm) 2-3 rooms per day Afternoon Rounds Chief or Senior resident dependent Often starting after 6pm Advanced Practitioners Not integrated effectively – unclear expectations Attendings not utilizing the APs

4. Integrated AP Model Deadline and Discussions University of Connecticut - January 15 th, 2010 How do we control the duty hours ? What happens to the resident paradigm ? How many AP FTEs do we need ? Who’s going to pay for the extra FTEs ? Should we cap the surgical services ? Do the residents have to cover every case ? “Private” PA surgical service ? How do we maintain quality care ?

5. Integrated AP Model Plan of Action given - UConn GMEC 20 patient limit for each service Templated Call Schedule Strict adherence to the online duty hour reporting system – zero tolerance Add 1-2 APs to the daily OR coverage Monday – Friday 11a-11p consult coverage Afternoon rounds start at 430pm “White Service” – Fourth General Surgery Service Short stay and pathway patients

6. Integrated AP Model Three Advanced Practitioner Models Extender Model One or two APs working with team of residents No appreciable benefit for duty hours Replacement Model APs replace the entire resident team Mostly Physician Assistants ICU coverage Flexible OR assistance / consults Provide 24/7 coverage Affects the duty hour compliance significantly Integration Model

7. Integrated AP Model Integration Mode l Advanced Practitioners Supplement the resident paradigm Provide OR, consult, and oncall coverage as needed Flex into different resident roles Interface with Attendings as needed Weekday floor service rounds @ 430pm Cover Junior and Senior resident holes Templated call schedule – days, nights, and holidays Templated call schedule – days, nights, and holidays Well suited for PAs and APRNs Tremendous duty hour compliance gains Requires accurate AP FTE resources and training

8. Integrated AP Model Integrated AP role and the “White” Service Plan of Action Approved - Hartford Hospital Conditionally accepted - UConn GMEC February – October 2010 Added 8 new FTEs Total 17 AP FTEs July 2010 – White Service starts Replacement model General Surgery Faculty acceptance Chief - Senior resident concerns Group discussions Maintain the resident learning experience

9. Integrated AP Model White Service Daily coverage with two Advanced Practitioners Pathway and short stay patients BariatricsBreast Thyroid / Parathyroid Colorectal Pathway Ventral / Incisional Hernia Laparoscopic Cholecystectomy/Appendectomy Typical daily census 15-20 patients AP Professional Satisfaction

10. Integrated AP Model Benefits of the Integrated AP Model Duty hour violations markedly reduced No negative resident impact Successful Quality Care Patient satisfaction maintained Improved hospital discharge % No holes in the resident coverage/schedule Flexible resident floor and OR coverage Integrated education models Resourceful - defined Chief Resident support Improved OR charge capture Surgical Faculty acceptance

11. Monthly Comparison # Residents in OR after 5 PM

12. 1 st Assist Quarterly Charges

13. Patients Discharged Prior to 11 AM

14. HCAHPS Survey

16. Integrated AP Model Residents and APs need team approach Shared patient responsibilities and learning opportunities Resident Education - supported using the AP Integration Model Residents still own their respective services APs still responsible to the Chief Resident APs need clear expectations The ability to flex into different resident roles Need adequate Attending support Limits the to assist with Chief Resident work hours Overflow “White” service Provides a duty hour control mechanism Helps to busy resident services Promotes better hospital throughput