Crash Cart: December 17th, 2015 – When should our residents sleep?

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This week: What is more important – a resident’s sleep or minimal handoffs during patient’s stay? Plus, a modern day Bonnie and Clyde steal patients’ payment information from ED for a shopping spree. Catch up on the week’s critical reads from around the web, along with commentary by EPM senior editors and practicing physician guests.

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Residents can’t rest easy

A few years ago a rule was introduced to give residents much needed rest, now it looks like patient care is suffering due to the physician not seeing the patient all the way through. Original Article by Slate.

William Sullivan, DO, JD: I still remember the aftermath of the Libby Zion case. I also remember working 120 hour weeks during trauma rotations. Many attendings are still working overnight and then round in the morning which adds up to 30 hours in a row. Working 80 hours per week on a regular basis is tough on anyone. That’s why emergency medicine is such a great specialty – you can work as much or as little as you want. The work hour restrictions may help improve a physician’s work/life balance, but it’s been 12 years since these restrictions went into effect and we’ve now just decided to do studies to see whether they improve patient outcomes? Why now? And if work hour restrictions don’t improve patient outcomes, is it doing to create a debate as to whether it is better to have burned out physicians or better medical outcomes?

E. Paul DeKoning, MD, MS: Sometimes the best-laid plans go awry. I’ve often thought this might backfire. Seemed like a good idea at the time, but the implementation and enforcement was problematic. I’ve always been a big fan of sleep and napping is an art form, but anyone who has had to deal with scheduling residents to not violate workhours knows how challenging it can be. Not to mention the recently addition of naps. This is so much more of a challenge for our surgical colleagues. Imagine trying to cram enough surgical experience into your residency to ensure surgical competence for rare cases.  So glad I’m an EMP! I frankly think it’s hilarious that the additional sleep is on average 12 minutes. Shazam!  Only 8 minutes more and it qualifies as a power nap.

Nicholas Genes, MD, PhD: I think the unseen factor in all this work-hours discussion is electronic medical records. First, Bill asked, why are we studying errors now, as opposed to 12 years ago or more, when the measures were first implemented? A big part of the answer is that studying *anything* related to patients and outcomes has become much more feasible since widespread implementation of EHRs (the earlier studies cited by Slate were all based on studies and analysis of residents, not patients). Second, the concept of the “handoff” is relatively new – the term first appears in PubMed in 1994, and in 2004 it’s mentioned 9 times, before spiking at 177 mentions in 2013. This mirrors the rise in work-hours regulations but also the rise of EHR – I’d argue that handoffs were less important when notes were handwritten and almost certainly of higher quality Screen Shot 2015-12-14 at 2.13.28 AM(just look at an inpatient progress note today – it’s a collage of labs, radiology reports, cloned paragraphs from prior notes, etc). Ten years ago, residents could look at a progress note and get a quick sense of what needed to be done for a patient – that’s really not true today. Finally, the nature of residents’ work has changed, particularly inpatient work. In the 90’s and early 2000s, before reform, the resident was physically running around the hospital a lot more – to place orders, write notes, view films, even retrieve papers or books. I have to believe it was more exhausting than today, when all of these tasks can be accomplished from the computers in the call room. Maybe today’s residents aren’t sleeping more because the work isn’t so tiresome. So maybe the proper interpretation of events isn’t “medicine was wrong to implement work-hours reform back then” – it’s “medicine has changed, and what seemed appropriate in 2003 and 2011 isn’t appropriate in this EHR-centric era.”

William Sullivan, DO, JD: I’m going to disagree with some of Nick’s reasoning on work hours. Just because EMRs have now made things easier to study doesn’t mean that those things weren’t capable of being studied in the past. I’m not sure I’m on board with the whole “residents don’t need as much sleep because they aren’t running around the hospitals as much as they did before” concept, either. Maybe we need a study to look at these things.

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Myth Buster: Doc trainees do no not effect patient’s length of stay according to study

Some physicians worried medical students increased a patient’s time in the hospital but new research shows the effect is minimalOriginal Article by Penn News. // Accompanying Study by JAMA.

William Sullivan, DO, JD: So what if medical students did slow down care? First, they help keep the physicians sharp by making them explain their thought processes. Second, how else would be train future physicians? I personally enjoy working with students and residents and wouldn’t change my practices regardless of the study findings.

E. Paul DeKoning, MD, MS: Despite what some think, med-students are a good thing, especially in the ED. I think there is no better place to learn the clinical practice of medicine by practicing your H&P skills. It’s amazing the things they find out that we gloss over, not to mention being able to remind me of the critical rate-limiting steps of the Krebs Cycle. They are good for patients and they make us better teachers and clinicians. I agree with Bill, so what if they slow us down? If they are slowing you down, perhaps rethink your workflow. Precepting them can be done well and efficiently, and you just may be surprised how many patients love the extra attention. Medical students and residents are not future members of the specialty; they are current members, just at different stages of their careers.

Nicholas Genes, MD, PhD: I have to point out that Bill went from criticizing the lack of proper research for work-hours regulations in the prior piece, to saying “study findings won’t change my practice” for this piece. I’m just going to channel my inner Rick Bukata and say: urban academic centers are already so inefficient that we can’t expect the presence of a medical student would make things noticeably worse.

William Sullivan, DO, JD: Not really sure what Nick’s comment is getting at. Regarding work hours, if we’re going to make changes that affect an entire industry, shouldn’t the changes and expected results be discussed and shouldn’t there be some substantiation for the changes? Maybe we change work hours to avoid burnout and improve work-life balance. But we’ve got to have some clue about whether the changes will have the intended effect before we make the changes. In this case, work hour changes were made to improve patient care and no one ever thought to look and see if there was any basis for the decision. Then it took them more than a decade to start looking for a correlation? With medical students in the ED, the issue is patient throughput. Consider the policy implications if researchers had found a significant delay in patient throughput due to medical students. What happens then? Do we kick medical students out of the emergency departments to save a few minutes per patient? Of course not. The medical education process won’t change. In the former case, I’m criticizing changes made without any evidence to support them. It sounds good … it stifles the public outcry from a highly-publicized case … let’s do it. In the latter case, I’m noting that the process already in place is working well, that they are studying the outcomes of a process that is unlikely (even unable?) to change, and that no alternate process was proposed even if the process somehow could change. What was the purpose of the study anyway? Oh yeah. To “examine the association between presence of medical students in the ED and patient LOS.” What to do with the findings? Anybody’s guess. Although I suppose that if LOS and patient satisfaction increased with medical students in the ER, then a lot of hospital CEOs would be jumping on the medical education bandwagon.

Nicholas Genes, MD, PhD: Ok, thanks for clarifying, makes more sense now. But I have no doubt that, it a study showed that students, or residents, or something delayed patient throughput, then at least a few EDs would use that study to change policy (already in some places, medical students in EDs have gone from functional interns to glorified observers, either for safety/liability reasons or because their charting hurts billing workflows). As for studying the influence of resident work hours on patient errors, it’s a tall order even in the EHR era – just imagine pulling paper charts of patients where errors occurred, finding the names of the note-writers and trying to figure out if they were the same ones who placed orders and interpreted test results… then cross-reference that with their schedule and how long they’d likely been awake. It’s a lot easier to do with timestamped notes and orders, and audit logs – and EHRs can really facilitate matching cohorts based on age, comorbidity, and disease severity. I’m no study budget expert but I suspect EHRs would be enough to knock a 7-figure study down to 6 figures.. Of course I agree that anything on the scale of adjusting work-hours nation-wide should be studied, but imagine being a grant agency or someone in ACGME, 15 years ago. Would you be able to justify spending millions of dollars on research about something so “obvious” as letting residents sleep more? Critics would either laugh at the waste, or claim that studies are only being called for to protect the status quo a little bit longer. At least now there’s more equipoise, and a study would be more feasible.

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Ambulances now have access to the Xstat Rapid Hemostasis System for treating gunshot wounds

The Xstat system formerly approved for the battlefield can now be utilized in EMS. Original Article by MedGadget.

William Sullivan, DO, JD: I saw this at the last ACEP meeting during the mock mass shooting. Neat idea. Only drawback that I can see is the potential for retained foreign bodies since the sponges are smaller in size and being injected into a smaller wound. That being said, if the choice is between a retained foreign body and exsanguination from a gunshot wound, I think most people would choose the former. If you want to see how the device works, there is a YouTube video here.

E. Paul DeKoning, MD, MS: Seems kinda cool. Another crossover application from the battlefield. I’d be curious to know how easy or difficult it is to retrieve all of the sponges when it comes time for definitive wound management. Anyone who’s had to find that last piece of glass in a wound despite being able to “see it” on X-ray can appreciate the tedium.

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Couple steals information from more than 80 Emergency Room patients and goes on shopping spree

Kyle and Krystle Steed stole thousands of dollars to use on a $6000 Chanel bag and other designer merchandise. Original Article by NBC New York.

William Sullivan, DO, JD: As Glenn Reynolds from Instapundit says: Tar. Feathers. When hospitals ask for your social security number, this is an example of why NOT to give it to them. The article doesn’t say whether hubby worked in registration and got the stolen information directly from the patients or whether he worked in some other part of the hospital and inappropriately accessed the patient accounts. Either way, an article was published this past week predicting that within the next year, cyberattacks will compromise one third of all health care records due to lax security. Until hospital IT departments get up to speed, the less information that hospitals have about you, the better.

E. Paul DeKoning, MD, MS: Guess I’ll have to use my Nick Genes alias the next time I run out of my meds. Good thing we look such much alike.

Nicholas Genes, MD, PhD: Really breathtaking criminality – $300,000 fraudulent purchases and attempts at more than $1 million… this article says Kyle Steed is “responsible for cleaning surgical experiment in the emergency room” (I think they mean equipment, not experiment – the Daily News editors must have been snoozing). I guess staff continue to be the weak point when it comes to protecting patient privacy – this recent story about small-scale HIPAA violations from jealous exes and snooping staff showed that it doesn’t have to be a huge data breach to hurt people.

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