Article 1
Cumulative Effect of Flexible Duty- hour Policies on Resident Outcomes: Long- term Follow – up Results from the FIRST Trial. Khorfan R, Yuce TK, Love R, Yang AD, Chung J, Hoyt DB, Lewis FR, Bilimoria KY. Ann Surg. 2020 May;271(5):791-798.
The Flexibility in Duty House Requirements for Surgical Trainees (FIRST) trial looked at the impact of flexible duty hours versus standard 2011 duty hour policies on patient outcomes and resident well – being. This article presents the four year follow- up analysis.
For background, in 2014, the FIRST trial randomly assigned 117 general surgery residency programs to either standard duty hour policies or flexible duty hour policies. Programs that were assigned to the flexible duty hour waived limits on individual shift lengths and time off in between shifts, while still adhering to the 80-hour work week averaged over 4 weeks. Results after the first year demonstrated no difference in resident satisfaction, well – being, or education, which ultimately resulted in the July 2017 ACGME change allowing all programs to transition to flexible duty hours.
A survey was administered to all general surgery residents, though this analysis only included those who self - designated as “clinically active.” Outcomes evaluated were duty hour violations, resident satisfaction, continuity of care, and perceived negative effects on professional and personal factors. The survey was administered once per year from 2015 – 2018.
In regards to duty hour violations, there was no difference between the rate of residents reporting work hour violations between the flexible versus standard duty hour programs. Residents in the flexible duty hour programs reported decreased rates of lapses in continuity of care, handing off of active patients, missing operations, and missing conferences in comparison to residents within the standard duty hour programs. Residents continued to show satisfaction with the flexible duty hour programs (91.9% in 2015 94.3% in 2018, p < 0.05) over time, along with the percentage of residents stating satisfaction with their job and decision to become a surgeon. However, resident satisfaction with overall well- being declined slightly in both arms over the study period. In addition, the perceived negative effects of flexible duty hours on residents’ health, time with family and friends, time for hobbies, and feeling well rested decreased significantly over time, but these perceived negative effects were overall higher in the flexible duty hours group in comparison to the standard duty hours group.
There were several limitations identified. First, resident responses were collected from the same general surgery residencies each year, but the individual responses were not able to be linked to truly evaluate the longitudinal effect of flexible duty hours over time. This study did not link patient outcomes to changes in resident duty hours, as was done in the initial FIRST trial analysis, to see if there changes in these outcomes over time due to improvements in patient’s handoff and continuity of care. In addition, after the 2017 ACGME rule change, many more programs switched to flexible duty hours.
Overall, this study demonstrated the long term durability of the flexible work hours program for residents, in particular, perceived improvements in patient care and continuity, and conforming with duty hour restrictions. Despite these positive results, resident overall wellbeing declined in both study arms. The authors attribute this finding to the increased recent focus on physician well – being and wellness, leading to more awareness and recognition. As a result, additional work will be needed to improve the work environment of general surgery residents.
Article 2
Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons. Kelz RR, Niknam BA, Sellers MM, Sharpe JE, Rosenbaum PR, Hill AS, Zhou H, Hochman LL, Bilimoria KY, Itani K, Romano PS, Silber JH. Ann Surg. 2020 Apr;271(4):599-605.
The purpose of this study was to evaluate the effect of duty hours during training on patient outcomes.
Administrative claims files for Medicare beneficiaries who underwent general or orthopedic surgery were obtained for two time periods: July 1999 – June 2003 (traditional) and July 2009 – June 2013 (modern). Information on surgeon training and board certification was obtained from the American Medical Association Physician Masterfile. Surgeons were divided into four cohorts based on training eras (traditional versus modern): traditional experienced, traditional new, modern experienced, and modern new. Experienced surgeons had > 10 years of independent practice, whereas new surgeons had completed < 3 years of independent billing after residency. Traditional surgeons completed practice in the era prior to duty hour reforms. Modern surgeons completed residency following duty hour reforms. Duty hour reforms occurred in 2003.
The primary outcome measure was 30-day mortality. Additional outcomes studied included 30 day readmissions, anesthesia, time, and prolonged length of stay.
Patients were matched on principal procedure, age at admission, admission year, sex, emergent or transfer status, comorbidities, and major operative secondary procedure status. A propensity score was constructed for treatment by a new surgeon.
In the traditional group, there were 9297 experienced surgeons and 2762 new surgeons. In the modern group, there were 8503 experienced surgeons and 2119 new surgeons. The analysis evaluated ~50,000 matched patients from the traditional era and ~36,000 matched patients from the modern era.
After matching, the 30-day mortality rate for new surgeons was higher than experienced surgeons in both traditional and modern groups, but only statistically higher in the traditional era. In evaluating overall patient outcomes from both the traditional to modern eras regardless of surgeon status, there was no difference in 30-day mortality, 30-day failure to rescue, 30 day readmissions or death, ICU usage, or LOS. Modern era new surgeons required more anesthesia time (average: 9 minutes) than traditional era new surgeons. Patients of modern era new surgeons also had longer LOS and required more resources, in comparison to traditional era new surgeons. However, only LOS was significant. Within general surgery specifically, patients of modern era new general surgeons trended toward lower 30 days all location mortality and lower 30 day readmissions, in comparison to the patients of traditional era new general surgeons.
In summary, new surgeons from both the traditional and modern eras have overall higher 30 mortality rates in comparison to experienced surgeons from both eras, but there is no significant difference in the mortality between new surgeons trained in the traditional versus modern eras. New surgeons in both eras had no difference in ICU usage rate, LOS, failure to rescue, and 30-day resource cost when compared to matched experienced surgeons within the same areas. As a result, the study concludes that there is “no evidence to suggest that duty hour reform negatively affected the performance of new surgeons.”
Limitations of the study include the limited data of set patient operations from two surgical subspecialties, no discussion of changes in surgeon wellbeing with duty-hour reforms, and no discussion on the effect of fellowship and patient outcomes.
Article 3
Yield of screening for COVID-19 in asymptomatic patients prior to elective or emergency surgery using chest CT and RT-PCR (SCOUT): multicenter study. Puylaert CAJ, Scheijmans JCG, Borgstein ABJ, Andeweg CS, Bartels-Rutten A, Beets GL, van Berge Henegouwen MI, Braak SJ, Couvreur R, Daams F, van Es HW, Franken LC, Grotenhuis BA, Hendriks ER, de Hingh IHJT, Hoeijmakers F, Ten Holder JT, Huisman PM, Kazemier G, van Kesteren F, van Kesteren J, Keywani K, Kuiper SZ, Lange MDJ, Lobatto ME, du Mée AWF, Poeze M, van Praag EM, van Rossen J, van Santvoort HC, Sedee WJA, Seelen LWF, Sharabiany S, Sosef NL, Quanjel MJR, Veltman J, Verhagen T, van de Vlasakker VCJ, Weeder PD, van Werven JR, Wesdorp NJ, van Dieren S, Han AX, Russell CA, de Jong MD, Bossuyt PMM, Quarles van Ufford JME, Prokop MW, Gisbertz SS, Prins JM, Besselink MG, Boermeester MA, Gietema HA, Stoker J. Ann Surg. 2020 Dec;272(6):919-924.
The purpose of this study was to evaluate the utility of pre- operative screening for COVID – 19 with either chest – CT, RT – PCR, or both for asymptomatic patients undergoing elective or emergent general surgery requiring general anesthesia.
The study included 2093 patients without COVID 19 symptoms from 14 centers in the Netherlands. Of these patients, 1224 were screen by CT and RT – PCR, while 869 were screened by chest CT only. Early in the pandemic in the Netherlands, routine screening in asymptomatic surgical patients was completed via chest CT only. As the RT – PCR test became available, a nationwide Dutch protocol was released that advised pre – operative screening with a chest CT and the RT – PCR which was developed in April 2020. Chest CT scanning for COVID – 19 was evaluated using the CO – RADS classification, which graded the level of suspicion for COVID – 19 based on CT findings on a scale from 1 – 5 (1 – very low suspicion 5 – very high suspicion). A chest CT was deemed positive for COVID – 19 if the score was 4 or 5, and these cases were postponed if they were deemed elective. A CO- RADS 3 was considered an equivocal result, and the decision to postpone surgery was at the discretion of the surgeon.
The primary study outcome was the detection of COVID – 19 with chest CT and RT – PCR. Other outcomes included the relationship between screening results and community prevalence and operative management after screening.
Of the 1223 patients who were screened by both methods, 1.5% (18 patients) had a positive screening result, of which 14 tested positive using RT – PCR, while 8 were suspected positive based on chest CT results. However, concordant results (positive chest CT and RT PCR) were only seen in 4 patients. Chest CT findings were negative in ten of the fourteen patients who tested positive for COVID – 19 using the RT – PCR test. Of the 869 patients who underwent a chest CT alone, only five patients (0.6%) had a positive result based on CT findings.
Surgeries were postponed in 17 of the 18 patients who underwent combined screening. Two of the 18 patients who screened positive in the combined screening group developed COVID – 19 related symptoms within two weeks, so they may have been pre- symptomatic. Two other patients who screened positive in the combined screening group had tested positive one month before, but were asymptomatic for at least 2 days prior to testing. The remaining 14 patients of the 18 who tested positive never had any symptoms. Of the five patients who screened positive based on chest CT findings alone, none ever tested positive or developed COVID - 19 symptoms in the two weeks post the initial screening chest CT. Surgery was postponed in 2 of the 5 patients who underwent chest CT screening alone.
Combined screening in asymptomatic surgical patients demonstrated a yield of 1.5%, of which RT – PCR confirmed positive COVID – 19 infections in 1.1% of patients. Chest CT yielded an incremental yield of 0.4%, though these could have been false positives as none of these patients ever demonstrated signs of COVID – 19 infections. On the other hand, three patients who underwent CT by screening only ultimately developed symptoms of COVID – 19 post – operatively, suggesting that these infections were potentially missed by CT.
The rationale for pre- operative screening is due to the concern for post – operative complications related to COVID symptoms, and unrelated to their surgery, including ICU stays, potential viral shedding during aerosolizing procedures including intubation, and reducing use of PPE.
The study concludes that pre – operative screening with RT – PC identified COVD – 19 infections in 1 out of every 100 asymptomatic patients. The authors also concluded that the use of chest CT for screening of asymptomatic patients was not recommended. Pre – operative screening in asymptomatic patients undergoing elective and emergent surgery should be performed with RT – PCR.
Recent IDSA (Infectious Disease Society of America) guidelines recommend pre- operative screening of all asymptomatic patients undergoing surgery utilizing the RT – PCR test.
