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

Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

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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. - PowerPoint PPT Presentation

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Page 1: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

Operative Volume in the New Era: A Operative Volume in the New Era: A Comparison of Total Resident Operative Comparison of Total Resident Operative

Volume Pre vs. Post 80-Hour Work Week Volume Pre vs. Post 80-Hour Work Week Restriction ImplementationRestriction 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

Page 2: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

ACGME 2003 Duty ACGME 2003 Duty Hour RestrictionsHour 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

Page 3: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

Impact on operative experience Jarman 2004-projected losses of

100-200 cases Mendoza 2005-10-25%

reductions predicted by general surgery program directors

Page 4: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

Studies Showing Studies Showing Stable Operative Stable Operative

VolumeVolume Bland 2005- no difference in

total or chief resident volume Ferguson 2005- 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

Page 5: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

Studies Showing Negative Studies Showing Negative Impact on Operative Impact on Operative

VolumeVolume

Carlin et al. 2007- significant decrease in operative volume for PGY1, 2, and 4 residents and a decrease in first assist and teaching assist volume

Damadi et al. 2007- overall decrease in both chief and total operative cases

Kairys 2008-10% of residents at risk for not meeting the 750 total case requirement

Page 6: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

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

Page 7: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

Study ObjectiveStudy 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

Page 8: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

MethodsMethods

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, 2009

19 ACGME Defined Categories Operative Volumes Non-operative trauma excluded, leaving 18 categories for

comparison

Page 9: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

ResultsResults 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

Page 10: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

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 Restriction

After Duty Hour Restrictions

2001, 2002, 2003 2008, 2009

Number of Chief ResidentsMinimum RRC Requirements

17 12 P Value

Head and Neck 25 79.7 66.5 0.0326 *

Skin/ Soft Tissue/ Breast 24 50 54.7 0.3785

Alimentary Tract 72 119.5 122.3 0.7852

Abdomen 65 165.8 192.5 0.0536

Liver 4 8.5 10 0.3651

Pancreas 3 6.4 6.6 0.8062

Vascular 44 159.4 140.8 0.2741

Endocrine 8 33.8 37.4 0.2319

Trauma- Operative 10 26.2 13.5 0.0002 *

Trauma- Non operative 20 --- 41.1 ---

Thoracic 15 45.4 32.5 0.0164 *

Pediatrics 20 27.2 31.4 0.1268

Plastics 5 20.1 13.8 0.0301 *

Endoscopy 85 269.8 250.8 0.5644

Laparoscopic- Basic 60 166.2 231.3 0.0001 *

Laparoscopic- Complex 25 60.7 67.5 0.2921

Teaching Cases --- 15.9 9.5 0.1418

TOTAL CHIEF CASES 150 268.7 253.2 0.4278

TOTAL MAJOR CASES 750 1193 1109 0.2719

Page 11: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

ResultsResults

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

Page 12: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

DiscussionDiscussion

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

Page 13: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

DiscussionDiscussion

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

Page 14: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

DiscussionDiscussion

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

Page 15: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

DiscussionDiscussion

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

Page 16: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

DiscussionDiscussion 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

Page 17: Pamela J. Bruce, M.D., Stephen D. Helmer, Ph.D., Jacqueline S. Osland, M.D., Alex Ammar, M.D

ConclusionsConclusions

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