Major Finding: An ACGME-compliant staffing model with 13-hour trainee shifts and increased night coverage reduced length of stay by 18% and reduced hospitalization costs by 11% in a pediatric inpatient unit.
Data Source: UCSF administrative billing data.
Disclosures: The authors reported no disclosures.
GRAPEVINE, TEX. – July brings more restrictions on resident duty hours, but compliance with these requirements can result in reduced hospitalization costs and shorter lengths of stay, in a study by the University of California, San Francisco's Benioff Children's Hospital.
Researchers who analyzed an attempt to cut resident work hours by enlarging care teams and eliminating cross-coverage found that a new staffing model reduced hospitalization costs by 11% and length of stay by 18%.
Under new resident duty-hours requirements from the Accreditation Council for Graduate Medical Education now in effect, interns (PGY-1 residents) are limited to shifts of no more than 16 hours.
In September 2008, UCSF reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. The hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams. The goal was to increase “patient ownership” by reducing handoffs and to improve patient care by having a more consistent provider overnight, Dr. Glenn Rosenbluth, a pediatric hospitalist at the Benioff, said at the meeting.
“The idea was that a resident working a 30-hour shift at 2 in the morning might be more focused on just urgent issues, calls from the nurses, and potentially seeing the call room when they get some down time, whereas someone working a week of dedicated night shifts might be more awake and more interested in advancing care because they're a member of the primary team,” he said.
Prior to September 2008, general pediatrics patients were covered by house-staff teams of two interns and one senior resident working shifts of up to 30 hours. The interns took call every sixth night and senior residents took call every fifth night. They provided cross-coverage of patients on multiple teams at night. This meant that one team was working each night and covering for all other teams, Dr. Rosenbluth said.
After the reorganization, they expanded the house-staff teams to four interns per team, with each intern working 3 weeks of day shift and 6 consecutive night shifts. The shifts were about 13 hours. The changes allowed them to eliminate cross-coverage and to have a dedicated night team. The attending coverage by hospitalists was unchanged.
To study the impact of the new staffing model, the researchers performed a retrospective, interrupted time series cohort study using concurrent controls. The target group was children who were admitted to the hospital's general pediatric service. The concurrent control group comprised surgical patients admitted to the same inpatient unit.
The researchers used the medical center's administrative billing data to analyze hospitalization costs and length of stay for children admitted to the pediatric medical-surgical unit from Sept. 15, 2007, through Sept. 15, 2009. They analyzed data on 280 patients before intervention and 274 patients after intervention, excluding patients who had spent time in the pediatric ICU and those who were on specialty services not covered by a pediatric hospitalist or general surgeon. The researchers used multivariate models to adjust for age, sex, the season of year, the admitting diagnosis, and any clustering at the attending level.
They found that for general pediatric patients admitted to the medical-surgical unit there was an adjusted rate ratio of 0.82 for length of stay following the intervention. That was an 18% decrease in length of stay from before the intervention. Similarly, hospitalization costs had an adjusted rate ratio of 0.89, an 11% decrease from before the intervention. Among the surgery patients who acted as the control group, there was no statistically significant change in the length of stay and there was a small increase in the cost of hospitalization.
The study suggests that costs associated with staffing changes needed to comply with the new duty-hours requirements could be offset by improved care efficiency, Dr. Rosenbluth said.
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New Era Requires New Strategies
I think as we move into the new frontier of continued restriction on resident duty hours, new ways and strategies need to be explored to maintain continuity and ownership of the patients we provide care for. Both of these areas have been negatively impacted by the continued restrictions.
This study suggests a night float model is an effective strategy to combat the problem thus decreasing LOS and patient handoffs. I suspect the authors are correct in their assessment, but I would like to see a prospective analysis to control for some confounding variables, plus I wonder what the attending staff model looked like over the same time period.
