Introduction

The Accreditation Council for Graduate Medical Education (ACGME) instituted the implementation of 80-hour workweek restrictions for residents in 2003. The aim of the regulation was to address fatigued residents and reduce medical errors by tracking maximal weekly work hours, shift length durations and total hours worked monthly for all residents.1 However, there are mixed opinions on the efficacy of such changes. Supporting data has shown the shift in work hours improved the surgical patient care,2 surgical education,3,4 operative volume during training and quality of life of surgical resident.5–7 However, opposing data for the hours restriction implementation also showed reduction in operative cases performed by chief residents and adverse effects in the continuity of care of patient.8,9

Currently, studies concerning the 80-hour workweek restriction mainly focused on how the adjustment in the trainee schedule can be carried out to abide to the regulation.10 One of the main objectives of the change was to ensure a satisfactory and safe resident job performance and avoid medical error.11 The grueling hours of surgical training have been thought to be a gateway to gain surgical exposure during the training experience. In order to overcome the dilemma of fulfilling the hours restriction and acquiring surgical experience, there have been some reports of duty hour falsification.12 As a free-standing, rural surgical training program, which has a limited support network, we had an exorbitant number of reported 80-hour violations in the past. The enthusiasm of our residents towards the training and patient care made unreported work hours violation become a pressing issue.

The long-term professional career development of surgical residents and the quality of lifelong education has been linked to social wellbeing.13–15 We believe a balanced learning environment for the residents is a key to success for a sustainable long-term surgical career. In 2016, we reformed the work hours in our program by implementing a multifaceted approach; to ensure the trainees fulfilled the 80 hours restriction, we implemented the electronic health record (EHR) software, an active resident self-reporting computer system, and a weekly hour report. The execution of the three operations in unison was to provide a comprehensive assessment in the resident work hours and prevent false hour entry. We have restructured our rotations into 4-week blocks to simplify the calculations of weekly hours. We have calculated and implemented strict weekly hour requirements specific for each one of our core surgical services: Trauma and Emergency General Surgery, General Surgery Elective Service, Vascular Surgery Service, and Surgical ICU, as well as Night-float service. The weekly hour requirements have totaled less than 80 hours each week, including the weekend call. To accomplish this, we have employed a policy of one weekday off during the week to offset the hours over 80 hours; especially associated with Saturday call.

Handoffs of patient care have been integral to the continuity of patient care.16 We instituted a one-hour timeframe to encompass the reevaluation of patient care, completion of clinical responsibility, and preparation of handoffs. The implementation of “one-hour” preparation ensures the quality of handoffs and the adequate transition of patient care to the next shift.

The goal of this quality improvement project was to evaluate the effectiveness of compliance to the 80-hour work rules in a single rural surgical training residency program with the aid of EHR. The primary outcome of this project was the number of violations to the 80-hour rule of the residents before and after implementation of those measures. The secondary outcomes were the academic and clinical performance of the residents. This project also evaluated the overall cultural change and satisfaction with the program from the ACGME survey data.

Methods

Data Collection

The data were collected from the ACGME resident survey for Guthrie Robert Packer Hospital. Guthrie Robert Packer Hospital is a tertiary care teaching hospital with 267 beds serving the northern tier of Pennsylvania and the southern tier of New York. There are 8 residency programs and fellowship programs provided for graduate medical education. The data derive from the self-reported electronic resource and the ACGME survey in general surgery residency. The survey was carried out confidentially on an annual basis. The areas of survey can be found at http://www.acgme.org/Portals/0/ResidentSurvey_ContentAreas.pdf.

Individual area was rated in 5 points with the highest as 5 and lowest as 1. The 80-hours work rules violation frequency was recorded from the self-reported electronic system, where each resident verified their individual working hours per week. The electronic reports were directly sent to the program director and the program coordinators. The American Board of Surgery (ABS) Qualifying Examination (QE) and Certifying Examination (CE) results were collected from the ABS with the consent from the residents.

80-Hours Violation Frequency: The number of violations of the 80-hours regulation was collected from a self-reported electronic system. All the residents were required to log their working hours weekly. The violation of 80 hours was reported to the program director panel. The frequency of violations was recorded from 2012–2018. The data from 2013–2015 and data from 2016–2018 were distinguished for data analysis with the strict implementation of the electronic health record (EHR) software in 2016.

Electronic Health Record Software for Login Time outside Regular Working Hours: An Epic (electronic health record) login duration and the time of each individual resident was reported to the program director directly on a monthly basis. The number of Epic logins outside regular working hours was reported to the program director panel. The program director addressed individual residents with prolonged Epic sessions.

Restructuring of the Core Rotations: After restructuring the core rotations, the calculated 4-week average varied by subspecialty; General Surgery Elective and Vascular Surgery residents logged 70-76 hours with 5 days off, Trauma/Emergency General Surgery recorded 76 hours and 5 days off, Surgical ICU measured 75 hours with 6 days off and Night-float averaged 74 hours with 5 days off. Rotations were changed from 12 to 13 blocks. Residents were scheduled to work a maximum of 13 hours per day beginning at 0600 and OR time concluding by 1700. Resident sign-out occurred no later than 1800 and involved briefing the night-float team. During each 4-week rotation, residents were assigned one Friday call, one Saturday call and four hours of transitional call. This added an additional 46 hours to their 260 hour/4-week schedule reaching a maximum of 306 hours and weekly average of 76.5 hours.

Clinical Practice for the Handoff Transition Period—Ensuring One Hour of Preparation: In 2016, a culture change of excusing all residents from the OR one hour before handoff to the night team was implemented. The aim of this was to allow all the residents to use this time to offload their clinical responsibilities. At this time, each resident is required to report to their team chief for preparation of handoffs and/or continuing the clinical duty. The program director and the chair of the department checked the operating rooms at 5 pm to remind the residents of the scheduled transition period. The residents, chief residents and attending surgeon all play a role in abiding to the OR schedule; the residents volunteer if they need to leave the OR, the chief residents inform the OR staff if the resident lost track of time, and the attending surgeon notifies the system in order to let the resident leave the OR at 5 pm. The service team meets in the resident office to report clinical duty resumption and/or handoff preparation.

Statistical Analysis

Data were analyzed with unpaired t test. A P value less than .05 was considered statistically significant. Statistical analysis was performed using the Prism version 8 software (GraphPad Software, La Jolla, CA).

Results

Number of Violations to 80-Hour Rule after Implementation of EHR: The number of violations of the non-EHR period was 151, 193, and 158 violations in 2013, 2014 and 2015, respectively. The number of violations decreased to 44, 16, and 14 in 2016, 2017 and 2018, respectively. The number of violations under EHR enforcement significantly decreased compared with the non-EHR cohort (mean EHR = 24.6, non-EHR= 167.3, p = 0.0009) (Figure 1A).

Board Examination Results: The ABS CE of the cohort under EHR enforcement had a higher passing percentage compare with the non-EHR cohort (N = 8, Passing % EHR = 80%, non-EHR = 64%) (p = .03) (Figures 1A and 1B). The ABS QE of the cohort under EHR enforcement had comparable outcomes to the non-EHR cohort. (N = 8, Passing % EHR = 93%, non-EHR = 100%) (p = 0.1) (Figures 1B and 1C).

Number of Operative Cases as Chief Resident: We found the EHR enforcement had little effect on the total number of operative cases performed by graduating chief residents (N = 8, Mean EHR = 1110, non-EHR= 1062) (p = 0.5) (Figure 1D).

ACGME Survey

80-Hours Compliance: The 80-hours compliance of the cohort under EHR enforcement was higher than the non-EHR cohort without statistical significance (mean compliance %, EHR = 96%, non-EHR = 52%) (p = 0.08) (Figure 1E).

Culture to Work on Patient Safety: The culture to work on patient safety under EHR enforcement had a similar outcome to the previous cohort (mean EHR = 4.4, non-EHR = 4.1) (p = 0.2) (Figure 1F). The information loss between the transfer of shift had no statistical difference between the two cohorts (mean EHR = 3.9, non-EHR = 3.8) (p = 0.2) (Figure 1G). In terms of multidisciplinary professional clinical practice, the interprofessional teamwork under EHR enforcement had a better outcome than the previous cohort with statistical significance (mean EHR = 4.5, non-EHR = 4.3) (p = 0.02) (Figure 1H). The effectiveness of interprofessional teamwork under EHR enforcement had a higher rating than the previous cohort without statistical significance (mean EHR = 4.3, non-EHR = 3.8) (p =0.1) (Figure 1I).

Faculty Supervision: The faculty supervision of both cohorts was similar without statistical difference (mean EHR = 4.4, non-EHR = 4.2) (p = 0.2) (Figure 1J).

Figure 1.Results

Figure 1A. The number of 80 hours rule violations in the cohort under EHR enforcement decreased significantly compared with the previous cohort (mean numbers violation: EHR = 24.6, non-EHR = 167.3) (p <0.05). Figure 1B. The ABS CE of the cohort under electronic health record (EHR) enforcement improved significantly compared with the non-EHR cohort. (passing % EHR = 80%, non-EHR = 64%) (p < 0.05). Figure 1C. In the Qualifying Examination (QE), both cohorts have similar outcomes (passing % EHR = 93%, non-EHR = 100%) (p >0.05). Figure 1D. Compared with the previous cohort, the number of operation cases of chief residents upon graduation in the cohort under EHR enforcement did not change significantly (mean number of operation cases per chief resident, EHR = 1110, non-EHR = 1062) (p >0.05). Figure 1E. The 80-hours compliance in EHR cohort is higher than that of the non-EHR cohort without statistical difference (mean compliance %, EHR = 96%, non-EHR = 52%) (p >0.05). Figure 1F. The culture to work on patient safety under EHR enforcement has a comparable outcome with the previous cohort (mean EHR = 4.4, non-EHR = 4.1) (p >0.05). Figure 1G. The information loss between the transfer of shift under EHR enforcement has a comparable outcome with the previous cohort (mean EHR = 3.9, non-EHR = 3.8) (p >0.05). Figure 1H. In terms of multidisciplinary professional clinical practice, the interprofessional teamwork under EHR enforcement has a better outcome with the previous cohort (mean EHR = 4.5, non-EHR = 4.3) (p <0.05). Figure 1I. The effectiveness of interprofessional teamwork under EHR enforcement has a comparable outcome with the previous cohort (mean EHR = 4.3, non-EHR = 3.8) (p >0.05). Figure 1J. The faculty supervision of the cohort under EHR enforcement has comparable outcomes with the previous cohort (mean EHR = 4.4, non-EHR = 4.2) (p >0.05).

Discussion

In this project, the number of violations to the 80-hour rule was reduced significantly following the implementation of the EHR measures. Additionally, the academic and clinical performance of the residents remained satisfactory and did not change significantly after EHR implementation. In fact, this project found that the certifying examination passing rate was improved significantly during this time, barring external factors. Others have shown similar findings in the American Board of Surgery In-Service Training Examination (ABSITE). Barden et al.7 demonstrated that the junior residents had the mean ABSITE percentile score improved. Hassett et al.3 showed the first-time passing rate of the ABS QE has significantly improved after imposing the hour restriction. One possible explanation for this phenomenon may be the improved operative experience and optimized time in the operation room.17 It has been shown that the ABSITE performance is directly proportional to the number of operations that the trainee attended.18

We demonstrated that the safety of patient care can be maintained while implementing the 80-hour workweek in surgical training. We also found that the “one-hour” transition preparation was invaluable to avoiding the loss of patient care information between providers. Also, the supervision and instruction provided by the attending physician were not affected by the change of work hours. Similar results have been shown in other specialties; Landrigan et al.19 showed that there was a significant reduction of medical error, including medication and ordering errors, and a significant reduction of occupation hazard exposure among the residents in a large cohort study of pediatric residents. In critical care training, the regulation of work hours was shown to significantly decrease serious medical errors among interns.20 Gottlieb et al.21 demonstrated that the length of stay has been shown to be reduced by the regulation of work hours. Our data showed that the EHR time-monitoring allowed for the maintenance of high-quality patient care, the minimization of medical error, the preservation of pertinent patient care information, the avoidance of occupation hazard, and an overall improvement in surgical training.

The wellbeing of residents was not the sole interest of this project. However, the performance of working effectively in an interprofessional team can be an indirect marker of resident wellbeing. Social belonging has been shown to be an important predictor of surgical resident wellbeing.14 The effectiveness performance in the interprofessional team showed that our trainees had developed socialization skills which are required for social wellbeing. The social factor can be multi-factorial. Antiel, et al.9 found a marked improvement of resident quality of life under the effect of duty hour restriction. Also, the individual resident’s wellbeing has been shown to be significantly related to the self-efficacy among other surgical residents.15 Our project showed that our residents had effective communication in the inter-discipline setting, which demanded a degree of self-efficacy. The results of this project may have been an incidental finding of improvement of wellbeing after the hour restriction.

One of the limitations of this project is that the data come from one single rural surgical training program. Thus, the results may not be generalizable to the effectiveness of the policy we used. We recommend further study comparing different residency programs with the use of EHR and without the use of EHR. The further study can be strengthened by increasing the sample size with comparison between the two groups in the same time frame. However, this limitation is also a strength in that the 80-hours duty regulation has been shown to be promising not only in a large cohort, but also in a small cohort in a rural surgical residency program. The faculty staff mobility in our program has been relatively low. The stable faculty staff status in this project helped to avoid confounding factors such as a high new faculty recruitment rate in the implementation of the combined strategy to ensure the strict 80-hours restriction.

We evaluated the ACGME survey data in this project. This might provide some useful information on the overall cultural change and degree of satisfaction with the program performance. However, this dataset provided only ancillary information. There was a possible reporting bias in the survey. We recommend further study with improved transparency of a reporting system to the third party, i.e., the party outside the residency to prevent reporting bias.

Another limitation of this project is that the psychosocial factor of the residents was not thoroughly investigated. The essential personal qualities, including confidence, grit and cognitive performance, are of high value in a surgical career. Confidence has been investigated by the UC Irvine group, though it has been shown to be difficult to measure.22 Grit, a measure of perseverance, has been shown to be important to avoid attrition in surgical training.23 Cognitive performance, which is defined as mental capability of learning, attention and independent thinking, is an important psychosocial factor to be considered.24 It reflected in the psychiatric morbidity in residents and faculty and played a vital role in ensuring patient safety.25 Those are important parameters to determine the psychosocial wellbeing of the residents. Unfortunately, those data were not collected in this cohort studied.

Thirdly, some clinical parameters not provided in this project may be of important value to show the improvement of patient care. Length of stay, average mortality rate and the surgical complication rate are some factors that would provide insight into the overall clinical performance of residents following policy implementation. However, those parameters can also be confounding factors in that patient care is now multidisciplinary.

In summary, this quality improvement project showed that reduction in work-hours violations during surgical residency can be achieved with the aid of EHR. Our data showed that adherence to work-hour guidelines is beneficial for resident clinical learning environment without diminishing operative experience. Further studies are warranted for a large cohort investigation for resident wellbeing.


Publisher’s Note

This article was reformatted after publication as part of The Guthrie Journal’s move to a new platform so that all of our articles would have a consistent look. The article was published March 18, 2021, and reformatted in March 2022. While no substantial changes were made, several silent corrections were made to capitalization (for instance, “electronic health record” and “mean” were made lowercase where appropriate), punctuation, and hyphenation (for instance, “well-being” / “wellbeing” was made consistent throughout). These changes were made for consistency and readability. Additionally, DOIs were added to references. Some of the article information included in the body of the original published version (for instance, word count and number of references) was removed from this version. A PDF of the originally published version from the former site will be made available on request.