Resident duty hour regulations: time for reassessment and revision

Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work

BACKGROUND

The association between long work hours and outcomes among attending surgeons remains an issue of debate.

OBJECTIVE

To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons.

METHODS

We executed a cohort study with unruptured cerebral aneurysm patients, who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis.

RESULTS

Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. There was no difference in inpatient mortality (adjusted difference, -0.7%; 95% confidence interval [CI], -1.4% to 0.02%), discharge to a facility (adjusted difference, -0.1%; 95% CI, -1.2% to 1.2%), or length of stay (adjusted difference, -0.58; 95% CI, -1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not.

CONCLUSION

Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences in mortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.

An Analysis of the On-Call Clinical Experience of a Junior Neurosurgical Resident

The process of transforming a medical student to a competent neurosurgeon is becoming increasingly scrutinized and formalized. However, there are few data on resident workload.

We sought to quantify the workload and educational experience of a junior resident while “on-call.”

A single resident's on-call log was reviewed from the period of July 1, 2014 to June 30, 2016, corresponding to that resident's postgraduate years 2 and 3. For each patient encounter (ie, consult or admission), information pertaining to the patient's demographics, disease or reason for consult, date/time/location of consult, and need for any neurosurgical intervention within the first 24 hours was collected.

In total, 1929 patients were seen in consultation. The majority of patients were male (62%) with a median age of 50 years (range, day of life 0-102 years) and had traumatic diagnoses (52%). The number of consults received during the 16:00 to 17:00 and 17:00 to 18:00 hours was +1.6 and +2.5 standard deviations above the mean, respectively. The busiest and slowest months were May and January, respectively. Neurosurgical intervention performed within the first 24 hours of consultation occurred in 330 (17.1%) patients: 221 (11.4%) major operations, 69 (3.6%) external ventricular drains, and 40 (2.1%) intracranial pressure monitors.

This is the first study to quantify the workload and educational experience of a typical neurosurgical junior resident while “on-call” (ie, carrying the pager) for 2 consecutive years. It is our hope that these findings are considered by neurosurgical educators when refining resident education.