The 80-hour work guidelines and resident survey perceptions of quality

Abstract

Objective: We hypothesized that resident fatigue error should improve, related to well-rested trainees as a direct cause/effect benefit. However, patient hospital care quality is multifactorial, so impact on patient care quality by changing only one variable for a single caregiver group was unknown.

Design and participants: Convenience samples of 156 residents from three surgical specialties were administered a questionnaire in early 2004 addressing perceptions of patient care quality before and after the 80-h workweek. Additionally, residents recently under work-hour restrictions (Newly Restricted, NR) were compared to New York state trainees already regulated by work-hour restrictions (Previously Restricted, PR).

Setting: Surgical residency training venues.

Main outcome measure: Survey results; the level of significance for all tests was 0.05.

Results: The participation response rate was 94.5%. Eighty-eight percent of respondents indicated by survey subjective impression that patient care quality was either unchanged (63%) or worse (26%) due to work-hour restrictions (P = 0.003). PR residents were more likely than NR residents to report unchanged or worse quality of care (P = 0.015). Residents overall did perceive improvement in some types of error with fewer fatigue-related errors (P < 0.001), e.g., medication (P < 0.001), judgment (P = 0.001), and dexterity (P = 0.013), subsequent to work-hour restrictions. However, more errors were perceived related to continuity of care (P < 0.001), miscommunication (P = 0.001), and cross-coverage availability (P = 0.001).

Conclusions: Despite an expected perception of improvement in fatigue-related errors, most participants (particularly PR residents) reported impressions that patient care quality had remained unchanged or had declined under the work-hour restrictions. Unresolved challenges with continuity of care, miscommunication, and cross-coverage availability are possible explanations. Mere work-hour reduction does not appear to improve patient care quality automatically nor to decrease the possibility for some types of error. Process interventions that specifically target trainee sign-out coverage constraints as part of a global reassessment will be important for future attempts to enhance quality hospital patient care.