Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations

Limits on resident work hours are intended to reduce fatigue-related errors, but may raise risk by increasing transfers of responsibility for patients. This study examines changes in outcomes for internal medicine patients after the implementation of work-hour regulations. The study was conducted in an urban, academic medical center and the sample included 14,260 consecutive patients discharged from the teaching (house staff) service and 6,664 consecutive patients discharged from the nonteaching (hospitalist) service between July 1, 2002, and June 30, 2004. Outcomes included intensive care unit utilization, length of stay, discharge disposition, 30-day readmission rate to the study institution, pharmacist interventions to prevent error, drug–drug interactions and in-hospital death.

The teaching service had net improvements in three outcomes. Relative to changes experienced by the nonteaching service, the rate of intensive care unit utilization decreased by 2.1 percent (95% CI, –3.3% to –0.7%; P = 0.002), the rate of discharge to home or rehabilitation facility versus elsewhere improved by 5.3 percent (CI, 2.6% to 7.6%; P < 0.001), and pharmacist interventions to prevent error were reduced by 1.92 interventions per 100 patient-days (CI, –2.74 to –1.03 interventions per 100 patient-days; P < 0.001). Teaching and nonteaching services had similar changes over time in length of stay, 30-day readmission rate, and adverse drug–drug interactions. In-hospital death was uncommon in both groups and change over time was similar in the two groups.

Limitations of the study are that it was a retrospective, nonrandomized design that assessed a limited number of outcomes. Teaching and nonteaching cohorts may not have been affected similarly by secular trends in patient care.

The authors conclude that after the implementation of work-hour regulations, three of seven outcomes improved for patients in the teaching service relative to those in the nonteaching service. They find no evidence of adverse unintended consequences after the institution of work-hour regulations.