Kyla Terhune, MD, Lesly Dossett, MD, MPH Vanderbilt University Medical Center

1. Surgical ICU Acuity and Volume Compared to Resident Workforce: Before and After the Duty Hour Regulations Kyla Terhune, MD, Lesly Dossett, MD, MPH Vanderbilt University Medical Center

2. Background • At Vanderbilt University Medical Center: • Appears to be an increase in “demand” • Aging, sicker, more complex patients • No concomitant increase in residents • July 2003: ACGME restrictions • further decrease in supply

3. Potential Hypotheses • Scenario 1: • Residents are working fewer hours… • Therefore see fewer patients… • Therefore “work” less hard and learn less… • Scenario 2: • Patient load and acuity have increased… • Even though residents are working fewer hours… • They are busier and working harder during that time.

4. Literature PRO • Safety unchanged or improved • Morale better • Education improved • No change: operative cases • No change: mortality CON • Safety declined • Attrition higher • Quality of med student education has declined • Significant decline in op cases (assists) • Higher complications

5. ICU and Work Hours • UT Southwestern (Frankel, H.L., et al. J Trauma, 2006.): • 2003: reallocated residents in SICU to comply w 80 hrs • 2004: SICU readmission rates (RR) doubled • Attributed increased RR to lack of continuity • Targeted intervention to reduce RR • UMDNJ (Gordon, C.R., et al., Am Surg, 2006) • Surveyed programs in order to determine strategies • Found 37% supplement with non-GS housestaff

6. ICU and Work Hours • Baylor: Trauma ICU • Morrison, C.A., M.M. Wyatt, and M.M. Carrick, J Surg Res, 2009 • National Trauma Data Bank (NTDB) • 2001-02 (pre) and 2004-05 (post) • Mortality decreased significantly

7. Hypotheses • Admissions to surgical ICUs (BICU, TICU, SICU) at VUMC have increased. • Patient acuity (as measured by hospital days and ventilator days) has increased. • Resident complement and work hours in these units have decreased.

8. Research Questions • How do changes in hospital acuity and volume compare to… resident numbers and work hours in the surgical critical care unit?

9. Tarpley RPM Metaphor • Remember vinyl records? • 33 1/3 RPM: pre 80-hour workweek • 78 RPM: post 80-hour workweek • My interpretation… Sinatra vs. Chipmunks

10. Methods: the Demand (Patients) • Admissions • TICU, BICU, SICU • Total initial admissions per month • Acuity • ICU-days per patient • Hospital-days per patient • Ventilator-days per patient (billing charge per 24 h) • Other measures of acuity (APACHE II)

11. Methods: the Supply (Residents) • Numbers • General Surgery residents • Supplemental residents from other services: • ED residents: TICU • Anesthesia: SICU • OB/Gyn: SICU • Hours

12. Methods: the Supply (Residents) • 1998-2003 • “We worked 110-120 hours per week.” • 36 hour call (6 am to 6 pm following day) • Non-call: 6 am to 6 pm • Did not assume days off, given unit months, acuity • Call schedule calculated by number of residents at that level • 3 interns: q3 • 2 seniors on trauma: q2

13. Sun Mon Tues Wed Thur Fri Sat Q2 week: 126 hours Q3 week: 112 hours

14. Methods: the Supply (Residents) • 2003-2008 • Hours data from department • Missing data (291/3718, 7.8%) • 80 hours (maximum) • Opted for 80: • worked “against” our hypothesis • Maximum they would be “allowed” to work

15. Comparisons of Pre/Post Hours Regulations • ICU Admissions • ICU days • Hospital Days • Ventilator Days • “Resident Days” (hours/24 hrs/day) • Comparable to total hours

16. Total ICU Admissions

17. Total ICU Days

18. Total Hospital Days

19. Total Ventilator Days

20. Total Ventilator Days • Reflect changes in practice • Increase in tracheostomies • Decreased sedation • Spontaneous breathing trials • “Wake up and breathe”

21. Total Residents on ICU Services

22. Total Residents on ICU Services • Residents were pulled from other services • Pulled residents from other hospitals • (loss of primarily operative services) • Initiation of closed units in SICU • Dedicated ICU team

23. Total Resident Days

24. Total Resident Days • Hours divided by 24 hrs/day • Unit similar to Hospital Days or ICU Days • Total resident days have increased • Increased number of residents in ICUs • But we have “maxed” out our supply

25. ICU Admissions: Resident Days

26. ICU Admissions: Resident Days • Comparing post to pre • More ICU admissions per resident days • More new patients and higher census • Slope not increasing • Proper supplementation of numbers of residents • Numbers are maxed out though…

27. ICU days: Resident days

28. Ventilator days: Resident days

29. Ventilator days: Resident days • Residents may be caring for fewer and fewer patients on ventilators • May reflect change in practice • However, still greater ratio in 2008 than in 1998.

31. Discussion • Are the hours correct? • Carpenter, R.O., et al., Am J Surg, 2006. • Adjustments prior to initiation of 2003 • Physician extenders • Moonlighters

32. Conclusions • ICU admissions have increased. • ICU length of stay has increased. • There is an overall increase in volume and acuity. • Redistribution of residents to ICU has been appropriate. • But volume is increasing. • Resident capacity is maxed out.

33. Conclusions • The acuity and volume of work in 2008 during working hours is greater than in 1998.

34. Conclusions • Critical Care Tower: November 2009 • Need more residents in ICUs? • Critical care track? • Certainly cannot afford to work fewer hours. • Patient safety • Maxed out physician extenders • Educational impact: • Removal from operative services? • Educational programs in the ICU

35. Acknowledgements • Stephanie Rowe • Allison Watts • Margaret Tarpley • Kelly Dilahuay • Linnea Hauge, PhD • Kim Schenarts, PhD • John Tarpley, MD