Did the change in regulation of resident duty hours disrupt patient care? In previous work, there was little indication that it affected patient survival.7, 8, 24
We now report the results of our examination of a measure of consequential but non-lethal disruption, namely the chance of a prolonged stay. The prolongation point is the day when the discharge rate starts to decelerate. Prolonged stays may result from complications that occur in the hospital, from inefficiencies in care, from high levels of acuity, or from various combinations of these events. Did prolonged stays become more or less common at teaching-intensive hospitals once resident duty hours were restricted? Some have argued that worse continuity of care would be disruptive, and logically could lead to longer stays.3–5
Others have suggested that reduced duty hours would increase the workload of residents when they were on call, possibly leading to longer stays because of increased errors or omissions.25
Still others have argued that more alert residents may commit fewer errors and potentially increase the discharge rate, thereby shortening length of stay.6
The good news from this study was that when analyzing prolonged stay we generally found results consistent with our previous mortality findings. Overall, the resident duty hour regulations of 2003 do not appear to have unfavorably changed the processes of care that lead to prolonged stays. Although some further investigation may be warranted for vascular surgery, our findings should provide reassurance that in both the non-Federal and VA hospital systems, the typical hospital had the resilience to provide services with similar efficiency despite major changes in staffing and care models that accompanied these regulatory shocks.
There are limitations to this report. Although we report on a large sample size based on administrative data, we lack detailed clinical data that may be present in the chart but not available to us for modeling. Furthermore, the VA experience may not be generalizable to the rest of the population because of differences between the VA patient population and the general US population (as was observed in ) and because VA hospitals are much more teaching intensive than non-VA hospitals. However, we examined the VA system precisely because it is so resident intensive, and for this reason examined in parallel Medicare patients cared for at any acute care hospital across the country, which are representative of the US healthcare system. Furthermore, we were not able to evaluate potential mediators of the impact of the resident duty hour reforms, such as the adoption of hospitalist models or changes in nurse staffing that were intended to compensate for the reduced availability of resident physician.
Further work will be required to better understand how hospitals successfully adapted to these changes, since there will, no doubt, be future calls for further changes in the workforce that cares for inpatients throughout the country. While the duty hour reforms of 2003 did not appear to have great impact on the probability of prolonged stays, we don’t know whether this is because there was a counterbalancing of the beneficial effects of reduced sleep deprivation25–27
with the detrimental effects of worsened continuity28, 29
or increased work intensity.25
The design of the duty hour reforms still allowed acute sleep deprivations as residents could work 30 hours in a row 25
and this may have contributed to the lack of observed changes in outcomes. Some hospitals reacted to the duty hour reforms by providing other caregivers to fill the gap left by the reduction in resident hours.29
Future study and testing of different approaches to duty hour reform will be needed to determine how to optimize patient safety and the efficiency of care—and to determine whether these reforms have other indirect effects on our health care system, the education of our healthcare professionals, and the health and satisfaction of our patients.