Introduction

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established the 80-hour work week for residents, and in 2011, it instituted additional regulations, which restricted shift length to 16 consecutive hours for interns.¹ These regulations shortened the shift length without a concurrent reduction in workload, thus creating work compression.² The consequence for resident education was less time to spend with and learn from patients.

We focused on the problem of work compression exacerbated by a clustering of admissions between 3 pm and 7 pm on call days in an internal medicine residency program. Our aim was to relieve work compression and improve the timeliness of patient care, time for resident learning, and resident satisfaction without reducing admissions to the teaching service.

Methods

Program Description

To relieve work compression from admissions clustering between 3 pm and 7 pm on call days, we implemented a 2-component intervention consisting of a front-fill system and a 90-minute window for admissions (figure). The 90-minute limit was derived from resident estimates of the tasks involved in an admission (box). Even if the last patient was assigned to the team at 7 pm, the 90-minute window allowed interns to complete call-day admissions by 8:30 pm, leaving an hour to review the patient list, sign out, and leave the hospital by 9:30 pm.

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Results

A total of 51 residents received surveys before and immediately after implementation of the new system, and 39 (77%) completed both surveys (table 1). Marked, significant improvements were found in all areas surveyed, which persisted at 6 months. Results were similar in the subgroup analyses of interns and upper-level residents, although not all survey items achieved statistical significance in the subgroups.

table 1 Resident Responses Regarding the General Inpatient Ward Experience: Pre- and Postintervention

^a

 This term represents an upper-level resident.

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More than two-thirds of residents felt that both the front-fill and the 90-minute rule were helpful and wanted to keep both components immediately postintervention (table 2). At the conclusion of the trial period in January 2015, the intervention was permanently implemented.

table 2 Resident Responses Regarding Intervention Components

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We achieved these results without an overall reduction in the number of patients admitted by residents, either in total admissions or the proportion of days during which teams admitted a full complement of patients (table 3). There were no reported patient safety events related to night float admissions.

table 3 Resident Admissions Preintervention and Postintervention

^a

Defined as literal days × 2 to account for 2 general ward teams.

^b

 Defined as both call teams taking 10 admissions and both teams on the third day of their call cycle receiving 2 patients from night float.

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Discussion

Call day modifications led to large, statistically significant improvements in residents' perception of time for learning and patient care, workload, and duty hours without reducing the number of admissions to the teaching service.

While prior interventions have been successful in relieving work compression, our approach required no additional funding. This intervention aimed to redistribute resident workload on call days, whereas previous studies decreased the number of patients per resident and required resource-intensive components.^4–6 Some programs have moved from a traditional bolus call system like ours (with teams taking new admissions on 1 day of the call cycle) to a drip system (with multiple teams taking fewer admissions daily), which has been shown to smooth daily discharge rates and statistically decrease length of stay.⁷ However, the impact of a drip system on resident hours, workload, and education is unknown, and our approach may be a less dramatic and feasible way of smoothing call-related workflow. Trials of duty hour flexibility may move us toward fewer duty hour restrictions^8,9; yet even with duty hour flexibility, clustering of admissions would continue, keeping the findings from our intervention relevant.

Limitations of this study include the lack of a control group. We also may have had results benefiting from the July effect of residents improving their efficiency through the academic year. However, a subgroup analysis of residents completing a ward rotation less than a month prior to the intervention (where we would expect less difference in experience) showed similar results to the overall group. Because our sample size was small, subgroup analyses were limited in their ability to achieve statistical significance (interns versus upper-level residents), and other analyses were not conducted (preliminary versus categorical interns). Our survey tool did not have validity evidence, and respondents could have interpreted questions differently from what was intended. We also did not directly measure time spent in patient care and educational activities, patient satisfaction, attending satisfaction, or night float resident satisfaction, potentially missing benefits and consequences in these areas. For example, some residents informally expressed less ownership or knowledge of front-fill patients, and formal assessment of patient care measures may have helped capture additional potential consequences.

Future considerations include modifying the 90-minute rule to 60 minutes later in the academic year, when interns become more efficient in their workflow, and adapting the modifications for other inpatient units.

Conclusion

Call day modifications (that included a front-fill with admitted patients and a 90-minute admission window) led to large, statistically significant improvements in residents' perception of time for learning and patient care, workload, and duty hours, without reducing the number of admissions to the teaching service.