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Maintaining Clinical Exposure

Following Mandated 2011 Residency

Program RedesignA retrospective review of programmatic changes of the Internal

Medicine Residency at Johns Hopkins Bayview Medical Center

Jonathon Thorp, M.D., M.B.A,

Senior Resident, Internal Medicine

Disclosures

• None

2

Presentation Objectives

1. Briefly review the historical context of the 2011

duty hour changes.

2. Explain how we applied the duty hour rules to

our internal medicine program.

3. Review the impact of these changes on volume

and types of patients seen by PGY1 trainees.

3

Historical Context

2003

• ACGME mandated a reduction in total hours worked

2008

• IOM report called for greater reduction in duty hours

2011

• ACGME regulated maximum continuous hours worked

4

IOM 2008

Philibert 2011

Philibert 2011

Continuous Hours Worked

• Pre-2011 • Post-2011

5

24

Hours

16

Hours

‡ didactic activities, transfer of patient care, outpatient clinics

+ 6‡

Hours

Types of Redesigns

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Workload Compression

Workload Reduction

Program Redesign

2006

• Aliki Initiative

• Curriculum: patient centered care and safe transitions of care

2009/10

• Resident Review Oversight Committee

• Goal: increase continuity and improve team based care

2011 & Current

• Application of Duty Hours

• Increased ambulatory & general acute care medicine

• Decreased critical care time & elective

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Study Design

• IRB approved

• Retrospective Analysis

• Data sources:

– Electronic Medical Record (i.e. Meditech)

– Administrative Billing Data (e.g. morality

data, case mix index)

– Program data (e.g. Demographic

information and training scores)

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Results: Program Redesign

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Admissions per PGY-1 trainee

per 4-day call cycle

2009 – 2011 7 patients

2011 – 2013 4 patients

Results: Program Redesign

10

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

No

. D

ays ±

Std

. D

ev.

Days on Service

Wards Critical Care Ambulatory Elective Vacation

All groups: P=0.00

Pre-2011

Post-2011

Variable2009-2011 2011-2013

P Valuemean (std. dev.) mean (std. dev.)

Total Inpatient

Encounters561.61 (63.43) 585.37 (125.92) 0.37

Unique Encounters 266.65 (36.58) 269.77 (62.16) 0.82

Unique & New

Encounters181.72 (25.45) 157.47 (40.47) 0.00

Follow up notes 379.89 (51.20) 427.90 (91.83) 0.02

Results: Inpatient Encounters

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Results: Outpatient

Encounters

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Variable2009-2011 2011-2013

P Valuemean (std. dev.) mean (std. dev.)

Outpatient Appointments

Scheduled 99.29 (5.03) 112.77 (18.42) 0.00

Attended 56.98 (6.59) 64.80 (10.85) 0.00

Results: Patient

Characteristics

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Variable2009-2011 2011-2013

P Valuemean (std. dev.) mean (std. dev.)

Quality Data

Case Mix Index

(CMI)1.51 (0.081) 1.54 (0.11) 0.31

30-day Readmission

Rate0.22 (0.023) 0.19 (0.022) 0.00

30-day Mortality

Rate0.064 (0.012) 0.062 (0.016) 0.59

Average Length of

Stay8.48 (0.66) 9.28 (0.98) 0.00

Workload Reduction

• Better educational outcomes

• Improved trainee satisfaction

• Increased conference attendance

• Decreased duty hour violations

• Reduced 30-day hospital readmissions

• Increased bedside interprofessional

rounds

April 29, 2015 14

Gonzalo 2014, McMahon 2010, O’Connor 2011, Record 2011, Thanarajasingam 2012

Preliminary outcomes of

mandated reforms

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30-day Mortality

30-day Readmission Rates

Surgical Morbidity & Mortality

Trainee Exam Scores

No D

iffe

rence

Patel 2014

Patel 2014, Block 2014

Rajaram 2014

Rajaram 2014

Limitations

• Objective educational outcomes are still in

data collection and analysis phase

• Encounter location may not be accurate if

note type was entered incorrectly

• Design did not allow for measurement of

face-to-face clinical time (e.g. time-motion

study)

• No inclusion of measures of burnout or

trainee fatigue 16

Discussion

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1. Increased ambulatory & general acute care medicine

rotations

2. Created and integrated a night team member into

acute care medicine teams

3. Despite lowering admission caps, total, unique, and

follow-up encounters were essentially unchanged

4. PGY-1 trainees cared for similar types of patients pre-

and post-duty hour reform

References

• Block L, Jarlenski M, Wu A, et al. (2014). “Inpatient Safety Outcomes Following the 2011 Residency Work-

Hour Reform. Journal of Hospital Medicine, 9:347-352.

• Institute of Medicine (2008). Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. 15 Dec 2008.

Web. Accessed 11 Jan 2015. http://www.iom.edu/Reports/2008/Resident-Duty-Hours-Enhancing-Sleep-

Supervision-and-Safety.aspx

• McMahon GT, Katz JT, Thorndike ME, et al. “Evaluation of a redesign initiative in an internal-medicine

residency.” NEJM 2010; 362(14):1304-1311.

• O’Connor AB, Lang VJ, Bordley DR. (2011). Restructuring an inpatient resident service to improve

outcomes for residents, students, and patients. Acad Med, 86(12): 1500-1507.

• Patel MS, Volpp KG, Small DS, et al. (2014). Association of the 2011 ACGME resident duty hour reforms

with mortality and readmissions among hospitalized Medicare patients. JAMA, 312(22):2364-73.

• Philibert, I., Amis, S. (Eds.). (2011). The ACGME 2011 duty hour standards: enhancing quality of care,

supervision, and resident professional development. Chicago, IL: ACGME.

• Rajaram R, Chung JW, Jones AT, et al. (2014). Association of the 2011 ACGME resident duty hour reform

with general surgery patient outcomes and with resident examination performance. JAMA, 312(22):2374-

84.

• Record JD, Rand C, Christmas C, et al. (2011). Reducing heart failure readmissions by teaching patient-

centered care to internal medicine residents. Arch Internal Med, 171(9): 858-859.

• Thanarajasingam U, McDonald FS, Halvorsen AJ, et al. (2012) “Service census caps and unit-based

admissions: resident workload, conference attendance, duty hour compliance, and patient safety.” Mayo

Clin Proc., 87(4):320-327

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Acknowledgements

• Colleen Christmas, MD

• Khalil Ghanem, MD

• Melissa Dattalo, MD

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Questions Thank you for your attention!

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