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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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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
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
Impact on operative experience Jarman 2004-projected losses of
100-200 cases Mendoza 2005-10-25%
reductions predicted by general surgery program directors
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
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
No previous published study has evaluated operative volume of general surgery residents who completed their entire residency after implementation of work-hour restrictions
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
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
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
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
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
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
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
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
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
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
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