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Clinical Investigations in Critical Care |

Introduction of a 14-Hour Work Shift Model for Housestaff in the Medical ICU* FREE TO VIEW

Bekele Afessa, MD, FCCP; Cassie C. Kennedy, MD; Kyle W. Klarich, MD; Timothy R. Aksamit, MD, FCCP; Joseph C. Kolars, MD; Rolf D. Hubmayr, MD, FCCP
Author and Funding Information

*From the Divisions of Pulmonary and Critical Care Medicine (Drs. Afessa, Kennedy, Aksamit, and Hubmayr), Cardiovascular Disease (Dr. Klarich), and Gastroenterology and Hepatology (Dr. Kolars), Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN.

Correspondence to: Bekele Afessa, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905; e-mail: afessa.bekele@mayo.edu



Chest. 2005;128(6):3910-3915. doi:10.1378/chest.128.6.3910
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Published online

Study objective: To describe the outcomes of switching housestaff from a traditional model of “long-call” every 4 days to a 14-h work-shift model in a medical ICU (MICU) over a 5-week pilot period.

Design: Retrospective comparison of a 5-week pilot period for a 14-h work-shift model vs a 4-month period for the traditional model.

Setting: The MICU of a tertiary medical center.

Participants: A total of 626 patients admitted to the MICU and 34 internal medicine residents taking care of them.

Interventions: None.

Measurements: Severity-adjusted patient outcomes, housestaff performance on end-of-rotation examinations, and scheduled duty hours during the 5-week 14-h work-shift pilot period compared to a 16-week traditional nonpilot work period.

Results: There were no statistically significant differences in patients’ adjusted mortality rates, hospital lengths of stay, or housestaff performance on end-of-rotation knowledge assessment examinations between the pilot and nonpilot periods. During the pilot period, each resident was scheduled to work for an average of 61.3 h weekly, and each fellow for 65.3 h weekly. In comparison, each resident and fellow was scheduled to work for an average of 73.3 h weekly during the nonpilot period.

Conclusions: The 14-h work shift is a feasible option for housestaff rotation in the MICU. Although the power of our study to detect significant differences in mortality, length of stay, and educational outcomes was low, there was no evidence of compromised patient care or housestaff education associated with the 14-h shift model over the course of this 5-week pilot study.

Figures in this Article

There is a growing body of literature on the real and potential adverse effects of prolonged duty hours for housestaff caring for hospitalized patients. The Accreditation Council on Graduate Medical Education (ACGME) has set specific duty hour limits for all housestaff in US training programs.1This has led to the introduction of shift work and night float systems in selected specialties.25 Although the optimal scheduling has not been determined, shift work is a common practice in emergency medicine.67 However, the potential negative impact on continuity of care that is inherent to shift models raises doubts about the safety and efficacy of these models in a medical intensive care practice. The Harvard Work hours, Health and Safety Group has shown8 that modification of the traditional housestaff schedule by introducing “night-call” and “day-call” interns eliminates extended work shifts, reduces the number of work hours, and decreases serious medical errors in the ICU. We piloted a 14-h shift model of rotation for internal medicine residents and critical care fellows in a 24-bed medical ICU (MICU) of a tertiary referral center for a 5-week interval to determine the feasibility of this model. The objective of this retrospective study was to describe the impact of this pilot program on patient outcomes, housestaff performance as assessed by end-of-rotation knowledge assessment examinations, and duty hours.

From March 27, 2004, to April 30, 2004, we piloted a 14-h shift-work model for internal medicine residents and critical care fellows in a 24-bed MICU. The outcomes during this pilot period were compared with those during the nonpilot period. We considered the 2 months before and the 2 months after the pilot to be the nonpilot period. During the pilot and nonpilot periods, the staffing support provided by allied health professionals was maintained at a constant level. The Institutional Review Board of the Mayo Foundation approved the study.

During the nonpilot period, the MICU was staffed by two critical care service physician teams, each consisting of one attending intensivist, two critical care fellows, and two first-year and two third-year internal medicine residents. The housestaff coverage included four to eight residents and two to four fellows during the days and two residents and one fellow during the nights. Each resident and fellow was on in-house call once every fourth night. Each workday started at about 7:00 am and usually ended with a sign-out round at 3:00 pm during the weekend and at 4:00 or 5:00 pm during weekdays (Fig 1 ). When residents and fellows were on in-house night call, they usually worked for 30 h, from 7:00 am to 1:00 pm of the following day (Fig 1). Each resident and fellow was free of duty for 1 day of each week. None of the residents and fellows had outpatient clinic responsibilities during the study periods. Teaching and patient management rounds took place every day. Formal didactic teaching took place for 30 min each morning starting at 8:00 am before patient management rounds. The work plans of the nonpilot period are detailed in Appendix 1.

During the pilot period, the MICU was staffed by two attending intensivists, six critical care fellows, and four first-year and four third-year internal medicine residents. The housestaff coverage included five residents and two fellows during the days, and two residents and two fellows during the nights. The fellows and residents worked in 14-h shifts, from 7:00 or 8:00 am to 9:00 or 10:00 pm(Fig 1). The details of the pilot period work plans are outlined in Appendix 2.

The housestaff rotated in the MICU for 4 or 5 weeks, and attending intensivists rotated for 1 or 2 weeks at a time. At the end of the rotation, all residents were required to complete a 20-item, web-based, multiple-choice examination. These clinical questions were constructed by intensivists who were actively involved in patient care and educating housestaff, and were drawn from a pool of 120 items that have been in use over the past 2 years.

We obtained the acute physiology score, acute physiology and chronic health evaluation (APACHE) III score, predicted mortality rate, predicted length of stay, as well as the actual mortality rate and length of stay of each hospital admission.910 Patients who did not authorize their medical records to be reviewed for research were excluded from the study. We used the severity-adjusted mortality rates and the length-of-stay ratios to assess the impact of the pilot period on patient outcome.11 The ratios for the lengths of MICU and hospital stays were defined as the ratios of the observed to the predicted length of MICU and hospital stay, respectively. The lower length-of-stay ratio reflects better performance. For patient outcome analysis, patients whose MICU care overlapped between the two periods were excluded from the study. During both periods of the study, there were structured schedules for the starting and ending of duty hours. The housestaff duty hours were calculated from the scheduled starting and ending times of their duties. No logs were in use to track the duty hours during the study period.

Descriptive data are summarized as the mean (SD), the median (interquartile range), or percentage. We used the χ2 test, the Student t test, the Mann-Whitney U test, and multiple logistic regression analysis test to determine the statistical differences between the two periods. The odds ratio (OR), standardized mortality ratio (SMR), and 95% confidence interval (CI) were calculated. P values of < 0.05 were considered to be significant. We performed post hoc power calculations to determine the adequacy of our sample size to detect differences in mortality, length of stay, and examination scores based on two-tailed tests.

Patient Care

Thirty-five patients who did not authorize their medical records to be reviewed for research and 15 patients whose MICU care overlapped the two study periods were excluded from the study. Based on the APACHE III database, the daily census was 16.6 and 14.4 patients, respectively, for the pilot and nonpilot periods. The baseline and outcome characteristics of the study patients admitted to the MICU during the pilot period are outlined in Table 1 . There were no statistically significant differences in demographics, predicted MICU and hospital mortality rates, or predicted MICU and hospital lengths of stay between the pilot and nonpilot periods. The APACHE III score was higher during the pilot period than during the nonpilot period. There were no significant differences in the observed MICU and hospital mortality rates and lengths of stay (Table 1). The MICU SMR was 0.539 (95% CI, 0.267 to 0.968) for the pilot group and 0.785 (95% CI, 0.579 to 1.042) for the nonpilot group. The hospital SMR was 0.672 (95% CI, 0.415 to 1.029) for the pilot period compared to 0.771 (95% CI, 0.609 to 0.962) for the nonpilot period. A logistic regression model, including the predicted hospital mortality rate to adjust for the severity of illness, comparing the two periods showed that the OR for hospital death during the pilot period was 0.83 (95% CI, 0.44 to 1.58) using the nonpilot period as the reference (p = 0.5686). Similarly, the OR for MICU death of the pilot period was 0.46 (95% CI, 0.17 to 1.22) using the nonpilot period as the reference (p = 0.1183). The mean (± SD) ICU length-of-stay ratio was 0.620 ± 0.536 for the pilot period compared to 0.663 ± 0.735 for the nonpilot period (p = 0.5188). The mean hospital length-of-stay ratio was 0.655 ± 0.637 for the pilot period compared to 1.262 ± 7.984 for the nonpilot period (p = 0.3740). Based on the 137 and 489 patients, respectively, included during the two periods of our study and the observed MICU and hospital mortality rates, and MICU and hospital lengths of stay, our study was underpowered to detect statistically significant differences (11% power for MICU mortality; 6% power for hospital mortality; 5% power for MICU length of stay; and 6% power for hospital length of stay).

Work Hours

Each housestaff was scheduled to work for an average of 73.3 h weekly during the nonpilot period. During the pilot period, each resident was scheduled to work for an average of 61.3 h weekly and each fellow for an average of 65.3 h weekly. Each of the 4 months of the nonpilot period included 28 days whereas the pilot period included 35 days. As the result of the uneven days during the pilot period, some of the housestaffs were scheduled to work more hours weekly than were others; two residents worked for 58.8 h, five residents worked for 61.6 h, one resident worked for 64.4 h, four fellows worked for 64.4 h, and two fellows worked for 67.2 h. During the nonpilot period, each resident and fellow was scheduled to work for an average of 73.3 h weekly, including a continuous period of 28 to 30 h when they were on duty overnight.

End of MICU Rotation Examination and Scholastic Activities

Eight and 26 residents, respectively, took the examination at the end of the MICU rotation during the pilot and nonpilot periods. The mean score during the pilot period was 86.9% (SD, 8.8) compared to 81.9% (SD, 16.6) during the nonpilot period (p = 0.4265). All eight residents during the pilot period wrote and presented case reports or reviews related to critical care by the end of their rotation. Based on the number of residents who took the examination and their scores, the power of our study in detecting statistically significant differences in the scores between the two groups was 12%.

This study describes our experience with a 14-h work-shift model for housestaff in the MICU of a tertiary, academic medical center. Although the study was limited by inadequate sample size, we were not able to identify any objective evidence of compromise in patient care or housestaff education associated with the model. All residents were able to complete scholastic work during the pilot period.

Although limiting housestaff working hours has not been shown to reduce patient mortality rates, it may influence other measures of patient outcome.1215 Interventions aimed at reducing the duty hours of housestaff have been shown to reduce medical errors, decrease length of hospital stay, and improve resource utilization.8,16The shift model piloted in our study reduced the duty hours of housestaff. However, it had the potential for more transfer of care between providers leading to discontinuous patient care. Previous studies1718 had shown that housestaff discontinuity of care might lead to preventable adverse events and longer hospital stays for patients. The potential harms and benefits that may arise from long duty hours with continuous care vs shorter shift models with less continuous care will need to be the focus of further studies. During the nonpilot period of our study, the nighttime housestaff coverage included two residents and one fellow. During the pilot period, the nighttime housestaff coverage was increased to two residents and two fellows. Although we expect this change to result in an improvement of patient care, we were unable to show significant differences in patient outcome between the two periods due to the small size of our study population.

There is evidence1920 showing that long duty hours may compromise housestaff learning by decreasing their attention span. Work shifts extended for ≥ 24 h pose safety hazards to housestaff.21Academic medical centers are expected to find alternatives to traditional patient care without sacrificing housestaff education.2223 One of the purposes of our pilot schedule was to determine whether a housestaff shift model in the MICU could be used as an alternative to the traditional schedule. Using the results of the examinations administered at the end of the MICU rotation as a surrogate, we did not find that the shift model compromises the education of residents. In fact, by completing their scholastic assignments, the residents gained more educational experience during the pilot period. In the nonpilot period, the residents did not have time to complete scholastic assignments.

The ACGME duty hours regulation requires that residents should not be on duty for > 80 h per week (when averaged over a 1-month rotation), should be free of patient care responsibilities 1 day per week, should not be on in-house call more than once every third night, should not spend > 6 h for patient care and didactic activities following a 24-h in-house call period, and should have a minimum of 10 h rest between duty periods.1 In our pilot period, the residents easily complied with the ACGME requirements and did not work over the assigned number of hours. During the nonpilot intervals, residents often felt compelled to stay beyond the mean period of 24 ± 6 h to wrap up work from busy call nights despite program requirements to the contrary. However, since we calculated the work hours based on the assigned schedules, not on the exact number of hours worked, we may have underestimated the number of hours worked during the nonpilot period.

The current study has several limitations. Our sample size analysis clearly showed that the small number of housestaff and patients included in the study and the short pilot period are major weaknesses. Since the study was performed in an MICU of a single institution with unique characteristics, our findings may not apply to other institutions or to other services of the same institution. We increased the number of fellows from four to six during the pilot period. Many medical centers do no have enough fellows for such staffing. The study did not have any objective data to assess the educational experience of the critical care fellows during both periods of the study.

Despite the limitations, our study shows that a 14-h shift model is a feasible option for housestaff rotation in the MICU. Although our study was limited to a small number of participants and a short period, there was no objective evidence of a harmful trend associated with the shift model. Future prospective studies should include larger numbers of participants, a longer study period, and measurements of patient satisfaction and fellow education.

  1. During the nonpilot period, the MICU service was split into two separate services (called “blue” and “green”). Each service consisted of one consultant, two critical care fellows, and two third-year and two first-year internal medicine residents. Each service was subdivided into two teams of one fellow, one third-year resident, and one first-year resident. Thus, there were four teams, and each team was on long call every fourth night. One team was also assigned to short-call responsibilities during weekdays (ie, Monday to Friday). The long-call team provided overnight coverage to patients on both services (blue and green). The short-call team was responsible for the first three admissions to the MICU from 7:00 am to 3:00 pm (defined by the time the patient arrives in the MICU). Short-call responsibilities ended by 5:00 pm. There were no short calls on weekends (ie, Saturday and Sunday) and holidays; on weekends and holidays, the long-call team was responsible for all admissions to the MICU and procedures. The housestaff coverage included four to eight residents and two to four fellows during days, and two residents and one fellow during nights. Each consultant was on call every other night.

  2. The housestaff started their workday at 7:00 am. When on long call, the duty hours ended at 1:00 pm the following day. The non-long call housestaff ended their duty at 3:00 pm on the weekend and holidays, and between 4:00 and 5:00 pm during the weekdays. Each housestaff had 1 day off duty each week.

  3. Triaging patients for MICU admission was performed by the third-year residents under the supervision of the fellows. Fellows were responsible for contacting the consultants for each MICU admission.

  4. The maximum number of patients admitted to the MICU by the first-year residents was five. When there were more than five admissions to the MICU, the workup was completed by the third-year residents and fellows.

  5. The admitting residents and fellows wrote MICU admission summaries and orders, and daily progress notes. Each patient had a minimum of one resident/fellow note and one consultant note per 24 h.

  6. There were management (work) rounds on each patient each morning and afternoon. The management and teaching rounds were sometimes combined.

  7. There was at least one teaching (attending) round every day.

  8. Sign-out rounds occurred around 3:00 pm on weekends and holidays, and between 4:00 and 5:00 pm on weekdays.

  9. Didactic sessions of the core critical care curriculum took place for a half-hour on weekdays, starting at 8:00 am. Sets of teaching slides were available to guide the daily didactic sessions. The slides were also available online to all residents.

  10. Mandatory weekly examinations with references and feedback were implemented online. There was also a mandatory time-limited final examination online to be completed by the fourth Thursday of the rotation. This final examination had to be completed within 45 min.

  1. Internal medicine residents and critical care fellows rotate in the MICU in shifts of 14 h, from 7:00 am to 9:00 pm and from 7:00 pm to 9:00 am. The day shift is made up of a team of two fellows and three residents, and the night team by two fellows and two residents. The MICU was staffed by two critical care attending consultants, who were on call every other night. The consultants are responsible for making sure residents complete their duty by 9:00 pm for the day shift and by 9:00 am for the night shift to comply with the housestaff duty hour regulations.

  2. Triaging patients for MICU admission is the fellows’ responsibilities. Fellows are also the first to be notified when any patient arrives in the MICU. The fellows are responsible for contacting the consultants for each MICU admission and call them for help when the workload becomes overwhelming. The fellows and consultants assign patients to the residents, based on the experience and competence of the residents.

  3. The maximum number of MICU admissions is two for a junior resident and three for a senior resident during any single shift. Once the maximum number of MICU admissions is exceeded by the residents (five for the night shift; seven or eight for the day shift), the fellows will be responsible for admitting patients. If fellows are too busy to do the MICU admissions, it is their responsibility to contact the consultants for help.

  4. The admitting resident, fellow, or consultant writes MICU admission summaries and orders. The team of residents and fellows for each shift are responsible for the care of all patients, including writing daily progress notes and updating MICU admission summaries. Updating transfer notes and completing the MICU discharge or death summaries are the responsibilities of the team on duty during the patients’ transfer or MICU discharge. Each patient should have one resident/fellow note per shift and one consultant note per 24 h. The note by the night team can be brief. The note by the day team should be comprehensive.

  5. There are management (work) rounds conducted with each patient at least once per shift, which is directed by the critical care consultant. The management and teaching rounds may be combined, but teaching rounds must occur for at least 4.5 h more per week than is required for management rounds alone.

  6. There is at least one teaching (attending) round per shift every day. The teaching rounds should be completed before 8:00 am for the night shift and before 8:00 pm for the day shift. It is strongly recommended that attending rounds occur between 10:00 am and noon, and between 10:00 pm and midnight.

  7. Sign-out rounds should start at 7:30 or 8:30 am and at 7:00 or 8:00 pm, and should be completed by 9:00 or 10:00 am and 9:00 or 10:00 pm every day. The consultants guide the sign-out rounds.

  8. Didactics of the core critical care curriculum take place for a half-hour on most days, starting at 7:00 or 8:00 am during the day shift. Additional half-hour didactic sessions are scheduled at night or during the day for the teams that cannot attend the 7:00 or 8:00 am didactic sessions due to off-days. All residents are expected to attend these didactic sessions.

  9. To assure consistency in the educational experience between ICUs and within units, sets of teaching slides are available to guide the daily didactic sessions. The slides are also available online for all residents. Mandatory weekly examinations with references and feedback are implemented online. There is also a mandatory time-limited final examination available online that should be completed by the fourth Thursday of the rotation. This final examination has to be completed within 45 min.

  10. The proposed model provides residents adequate free time to perform scholastic activities. Residents are expected to write a draft of a case report, review, or other research project related to critical care during their rotations and to submit it to one of the critical care consultants and the education coordinator by the end of their rotation. They are also expected to make a 10-min presentation of their projects during the fourth week of their rotation.

Abbreviations: ACGME = Accreditation Council on Graduate Medical Education; APACHE = acute physiology and chronic health evaluation; CI = confidence interval; MICU = medical ICU; OR = odds ratio; SMR = standardized mortality ratio

This research was supported by the Department of Medicine, Mayo Clinic College of Medicine.

Figure Jump LinkFigure 1. Scheduled weekly work hours of the nonpilot and pilot periods for interns, residents and fellows. MN = midnight; Intern = first-year internal medicine resident; Resident = third-year internal medicine resident.Grahic Jump Location
Table Graphic Jump Location
Table 1. Baseline and Outcome Characteristics of Patients Admitted to MICU During the Pilot and Nonpilot Periods*
* 

Values are given as the mean (SD), or mean (interquartile range), unless otherwise indicated. APS = acute physiology score.

The authors thank the Internal Medicine residency program leadership and chief residents, the pulmonary fellowship program leadership, the critical care fellowship program leadership and the MICU bedside nurses for their support in implementing the shift model.

Accreditation Council for Graduate Medical Education. Report of ACGME work group on resident duty hours. Available at: http://www.acgme.org. Accessed February 15, 2005.
 
Reader, DJ, Spigos, DJ, Bennett, WJ, et al The graveyard shift: experience with a night float system.Emerg Radiol2002;9,82-87. [PubMed]
 
Cavallo, A, Jaskiewicz, J, Ris, MD Impact of night-float rotation on sleep, mood, and alertness: the resident’s perception.Chronobiol Int2002;19,893-902. [CrossRef] [PubMed]
 
Paice, E, Reid, W Can training and service survive the European Working Time Directive?Med Educ2004;38,336-338. [CrossRef] [PubMed]
 
Cass, HD, Smith, I, Unthank, C, et al Improving compliance with requirements on junior doctors’ hours.BMJ2003;327,270-273. [CrossRef] [PubMed]
 
Dula, DJ, Dula, NL, Hamrick, C, et al The effect of working serial night shifts on the cognitive functioning of emergency physicians.Ann Emerg Med2001;38,152-155. [CrossRef] [PubMed]
 
Steele, MT, Ma, OJ, Watson, WA, et al Emergency medicine residents’ shiftwork tolerance and preference.Acad Emerg Med2000;7,670-673. [CrossRef] [PubMed]
 
Landrigan, CP, Rothschild, JM, Cronin, JW, et al Effect of reducing interns’ work hours on serious medical errors in intensive care units.N Engl J Med2004;351,1838-1848. [CrossRef] [PubMed]
 
Knaus, WA, Wagner, DP, Draper, EA, et al The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults.Chest1991;100,1619-1636. [CrossRef] [PubMed]
 
Knaus, WA, Wagner, DP, Zimmerman, JE, et al Variations in mortality and length of stay in intensive care units.Ann Intern Med1993;118,753-761. [PubMed]
 
Zimmerman, JE, Alzola, C, Von Rueden, KT The use of benchmarking to identify top performing critical care units: a preliminary assessment of their policies and practices.J Crit Care2003;18,76-86. [CrossRef] [PubMed]
 
Daigler, GE, Welliver, RC, Stapleton, FB New York regulation of residents’ working conditions: 1 year’s experience.Am J Dis Child1990;144,799-802. [PubMed]
 
Fletcher, KE, Davis, SQ, Underwood, W, et al Systematic review: effects of resident work hours on patient safety.Ann Intern Med2004;141,851-857. [PubMed]
 
Howard, DL, Silber, JH, Jobes, DR Do regulations limiting residents’ work hours affect patient mortality?J Gen Intern Med2004;19,1-7. [PubMed]
 
Laine, C, Goldman, L, Soukup, JR, et al The impact of a regulation restricting medical house staff working hours on the quality of patient care.JAMA1993;269,374-378. [CrossRef] [PubMed]
 
Gottlieb, DJ, Parenti, CM, Peterson, CA, et al Effect of a change in house staff work schedule on resource utilization and patient care.Arch Intern Med1991;151,2065-2070. [CrossRef] [PubMed]
 
Lofgren, RP, Gottlieb, D, Williams, RA, et al Post-call transfer of resident responsibility: its effect on patient care.J Gen Intern Med1990;5,501-505. [CrossRef] [PubMed]
 
Petersen, LA, Brennan, TA, O’Neil, AC, et al Does housestaff discontinuity of care increase the risk for preventable adverse events?Ann Intern Med1994;121,866-872. [PubMed]
 
Leonard, C, Fanning, N, Attwood, J, et al The effect of fatigue, sleep deprivation and onerous working hours on the physical and mental wellbeing of pre-registration house officers.Ir J Med Sci1998;167,22-25. [CrossRef] [PubMed]
 
Lockley, SW, Cronin, JW, Evans, EE, et al Effect of reducing interns’ weekly work hours on sleep and attentional failures.N Engl J Med2004;351,1829-1837. [CrossRef] [PubMed]
 
Barger, LK, Cade, BE, Ayas, NT, et al Extended work shifts and the risk of motor vehicle crashes among interns.N Engl J Med2005;352,125-134. [CrossRef] [PubMed]
 
Abrass, CK, Ballweg, R, Gilshannon, M, et al A process for reducing workload and enhancing residents’ education at an academic medical center.Acad Med2001;76,798-805. [CrossRef] [PubMed]
 
Nishimura, RA, Linderbaum, JA, Naessens, JM, et al A nonresident cardiovascular inpatient service improves residents’ experiences in an academic medical center: a new model to meet the challenges of the new millennium.Acad Med2004;79,426-431. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Scheduled weekly work hours of the nonpilot and pilot periods for interns, residents and fellows. MN = midnight; Intern = first-year internal medicine resident; Resident = third-year internal medicine resident.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Baseline and Outcome Characteristics of Patients Admitted to MICU During the Pilot and Nonpilot Periods*
* 

Values are given as the mean (SD), or mean (interquartile range), unless otherwise indicated. APS = acute physiology score.

References

Accreditation Council for Graduate Medical Education. Report of ACGME work group on resident duty hours. Available at: http://www.acgme.org. Accessed February 15, 2005.
 
Reader, DJ, Spigos, DJ, Bennett, WJ, et al The graveyard shift: experience with a night float system.Emerg Radiol2002;9,82-87. [PubMed]
 
Cavallo, A, Jaskiewicz, J, Ris, MD Impact of night-float rotation on sleep, mood, and alertness: the resident’s perception.Chronobiol Int2002;19,893-902. [CrossRef] [PubMed]
 
Paice, E, Reid, W Can training and service survive the European Working Time Directive?Med Educ2004;38,336-338. [CrossRef] [PubMed]
 
Cass, HD, Smith, I, Unthank, C, et al Improving compliance with requirements on junior doctors’ hours.BMJ2003;327,270-273. [CrossRef] [PubMed]
 
Dula, DJ, Dula, NL, Hamrick, C, et al The effect of working serial night shifts on the cognitive functioning of emergency physicians.Ann Emerg Med2001;38,152-155. [CrossRef] [PubMed]
 
Steele, MT, Ma, OJ, Watson, WA, et al Emergency medicine residents’ shiftwork tolerance and preference.Acad Emerg Med2000;7,670-673. [CrossRef] [PubMed]
 
Landrigan, CP, Rothschild, JM, Cronin, JW, et al Effect of reducing interns’ work hours on serious medical errors in intensive care units.N Engl J Med2004;351,1838-1848. [CrossRef] [PubMed]
 
Knaus, WA, Wagner, DP, Draper, EA, et al The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults.Chest1991;100,1619-1636. [CrossRef] [PubMed]
 
Knaus, WA, Wagner, DP, Zimmerman, JE, et al Variations in mortality and length of stay in intensive care units.Ann Intern Med1993;118,753-761. [PubMed]
 
Zimmerman, JE, Alzola, C, Von Rueden, KT The use of benchmarking to identify top performing critical care units: a preliminary assessment of their policies and practices.J Crit Care2003;18,76-86. [CrossRef] [PubMed]
 
Daigler, GE, Welliver, RC, Stapleton, FB New York regulation of residents’ working conditions: 1 year’s experience.Am J Dis Child1990;144,799-802. [PubMed]
 
Fletcher, KE, Davis, SQ, Underwood, W, et al Systematic review: effects of resident work hours on patient safety.Ann Intern Med2004;141,851-857. [PubMed]
 
Howard, DL, Silber, JH, Jobes, DR Do regulations limiting residents’ work hours affect patient mortality?J Gen Intern Med2004;19,1-7. [PubMed]
 
Laine, C, Goldman, L, Soukup, JR, et al The impact of a regulation restricting medical house staff working hours on the quality of patient care.JAMA1993;269,374-378. [CrossRef] [PubMed]
 
Gottlieb, DJ, Parenti, CM, Peterson, CA, et al Effect of a change in house staff work schedule on resource utilization and patient care.Arch Intern Med1991;151,2065-2070. [CrossRef] [PubMed]
 
Lofgren, RP, Gottlieb, D, Williams, RA, et al Post-call transfer of resident responsibility: its effect on patient care.J Gen Intern Med1990;5,501-505. [CrossRef] [PubMed]
 
Petersen, LA, Brennan, TA, O’Neil, AC, et al Does housestaff discontinuity of care increase the risk for preventable adverse events?Ann Intern Med1994;121,866-872. [PubMed]
 
Leonard, C, Fanning, N, Attwood, J, et al The effect of fatigue, sleep deprivation and onerous working hours on the physical and mental wellbeing of pre-registration house officers.Ir J Med Sci1998;167,22-25. [CrossRef] [PubMed]
 
Lockley, SW, Cronin, JW, Evans, EE, et al Effect of reducing interns’ weekly work hours on sleep and attentional failures.N Engl J Med2004;351,1829-1837. [CrossRef] [PubMed]
 
Barger, LK, Cade, BE, Ayas, NT, et al Extended work shifts and the risk of motor vehicle crashes among interns.N Engl J Med2005;352,125-134. [CrossRef] [PubMed]
 
Abrass, CK, Ballweg, R, Gilshannon, M, et al A process for reducing workload and enhancing residents’ education at an academic medical center.Acad Med2001;76,798-805. [CrossRef] [PubMed]
 
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