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 surgeryBurn/TraumaThoracic 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 SICUsAfter

• 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 email 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)

Answer Options Strongly Agree

Agree Disagree Strongly Disagree

No Change

1) I noticed that there were fewer adverse events on the ICU

1 6 23 0 44

2) It was more difficult for me to identify who was the house officer on duty

8 33 20 5 9

3) I felt more confident that the house officer on call knew how to take care of my patient

2 15 35 4 18

4) I went directly to the fellow or attending to answer simple questions more frequently

4 23 28 7 12

Nursing Attitudes Regarding a Reduction of Hours in House Shifts

Compared to before the most recent work hours change:

5) I went directly to the fellow or attending to answer complex questions more frequently

6 40 13 5 11

6) I went directly to the fellow or attending to deal with families more frequently

7 20 25 4 18

7) I had less interaction with the house staff regarding patient issues

5 18 25 7 20

8) I had more direct interaction with the attending staff regarding patient issues

4 32 16 1 22

9) Seems to me that residents know just as much about taking care of ICU patients as they did before the work hours change

3 22 32 7 12

Answer Options Strongly Agree

Agree Disagree Strongly Disagree

No Change

Nursing Attitudes Regarding a Reduction of Hours in House Shifts

Compared to before the most recent work hours change:

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.”

10) Physician extenders (PAs and NPs) and residents are interchangeable

0 9 30 10 6

Nursing Attitudes Regarding a Reduction of Hours in House Shifts

Answer Options Strongly Agree

Agree Disagree Strongly Disagree

No Change

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?