Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 142 No. 0304 (2012)

Morbidity in surgery: impact of the 50-hour work-week limitation in Switzerland

  • Reto Kaderli
  • Adrian Businger
  • Antoine Oesch
  • Ulrich Stefenelli
  • Urban Laffer
DOI
https://doi.org/10.4414/smw.2012.13506
Cite this as:
Swiss Med Wkly. 2012;142:w13506
Published
15.01.2012

Summary

PRINCIPLES: Work-hour regulations for residency programmes in Switzerland, including a 50-hour weekly limit, were set in on 1 January 2005. Patient safety was one of the major arguments for the implementation. As the effect of the restriction of residency work hours on patient care in Switzerland has not yet been evaluated on objective data, the aim of the present study was to assess its impact by comparing the patients‘ morbidity and mortality before (2001–2004) and after (2005–2008) the implementation.

METHODS: Retrospective analysis of records of the Spitalzentrum Biel AG, a large referral center classified according to the Swiss Medical Association, collected in the database of the Association for Quality Assurance in Surgery (AQC), a prospective database of consecutive patients undergoing surgical procedures in Switzerland. A selection of 2,686 patients with common surgeries, operated on by residents, was performed.

RESULTS: There were 1,259 (46.9%) patients meeting our inclusion criteria who were admitted during the period before introduction of work-hour limitation and 1,427 (53.1%) patients after introduction. The in-hospital mortality and postoperative surgical complication rate were significantly higher after the reform (p <0.05 and p <0.01, respectively). No significant differences could be found concerning the overall intraoperative (p = 0.61) and postoperative medical complication frequencies (p = 0.08).

CONCLUSIONS: The work-hour limitation implemented in Switzerland was not associated with surgical patient safety measure improvement for common surgeries (i.e., morbidity and mortality rate). Further research on a nationwide basis is needed to assess the value of the higher surgical complication and mortality rate.

References

  1. SECO Web site. Application of the labour law to residents working in public hospitals [homepage on the internet]; c2007 [cited 2011 Nov 20]. Available from: http://www.seco.admin.ch/aktuell/00277/01164/01980/index.html?lang=de&msg-id=9333.
  2. Pilot flight time and rest: fact sheet. Federal Aviation Administration, 2010 [homepage on the internet]; [cited 2011 Nov 20]. Available from: http://www.faa.gov/news/fact_sheets/news_story.cfm?newsId=6762.
  3. Halsted WS. The training of the surgeon. Bull Johns Hopkins Hosp. 1904;15:267–75.
  4. Wallack MK, Chao L. Resident work hours: the evolution of a revolution. Arch Surg. 2001;136:1426–32.
  5. Drazen JM, Epstein AM. Rethinking medical training – the critical work ahead. N Engl J Med. 2002;347:1271–2.
  6. Dawson D, Zee P. Work hours and reducing fatigue-related risk: good research vs good policy. JAMA. 2005;294:1104–6.
  7. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112–4.
  8. Dawson D, Reid K. Fatigue, alcohol and performance impairment [scientific correspondence]. Nature. 1997;388:235.
  9. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44:1017–22.
  10. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–48.
  11. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002;287:955–6.
  12. Bernstein M, Etchells EE. Does reducing interns’ work hours reduce the rate of medical errors? CMAJ. 2005;172:474.
  13. Goldman LI, McDonough MT, Rosemond GP. Stresses affecting surgical performance and learning. I. Correlation of heart rate, electrocardiogram, and operation simultaneously recorded on videotapes. J Surg Res. 1972;12:83–6.
  14. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator. Lancet. 1998;352:1191.
  15. Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ. 2001;323:1222–3.
  16. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, et al. Morality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975–83.
  17. Shetty KD, Bhattacharya J. Changes in hospital mortality associated with residency work-hour regulations. Ann Intern Med. 2007;147:73–80.
  18. Rosen AK, Loveland SA, Romano PS, Itani KM, Silber JH, Even-Shoshan OO et al. Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients. Med Care. 2009;47:723–31.
  19. Morrison CA, Wyatt MM, Carrick MM. Impact of the 80-hour work week on mortality and morbidity in trauma patients: an analysis of the National Trauma Data Bank. J Surg Res. 2009;154:157–62.
  20. Gopaldas RR, Chu D, Dao TK, Huh J, LeMaire SA, Coselli JS, Bakaeen FG. Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients. J Surg Res. 2010;163:201–9.
  21. De Virgilio C, Yaghoubian A, Lewis RJ, Stabile BE, Putnam BA. The 80-hour resident workweek does not adversely affect patient outcomes or resident education. Curr Surg. 2006;63:435–39.
  22. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events. Ann Intern Med. 1994;121:866–72.
  23. Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg. 2003;237:449–55.
  24. Fischer JE. Continuity of care: a casualty of the 80-hour work week. Acad Med. 2004;79:377–8.
  25. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243:864–71.
  26. Payette M, Chatterjee A, Weeks WB. Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions. Am J Surg. 2009;197:820–5.
  27. Kaderli R, Buser C, Stefenelli U, Businger A. Students’ interest in becoming a general surgeon before and after a surgical clerkship in German-speaking Switzerland. Swiss Med Wkly. 2011 Aug 15;141:w13246. doi: 10.4414/smw.2011.13246.
  28. Buddeberg-Fischer B, Stamm M. The medical profession and young physicians’ lifestyles in flux: challenges for specialty training and health care delivery systems. Swiss Med Wkly. 2010;140:w13134. doi: 10.4414/smw.2010.13134.
  29. Knecht M, Bauer GF, Klaghofer R, Buddeberg-Fischer B, Stamm M, Hämmig O. Work-life conflicts and health among Swiss physicians – in comparison with other university graduates and with the general Swiss working population. Swiss Med Wkly. 2010;140:w13063. doi: 10.4414/smw.2010.13063.
  30. Businger A, Guller U, Oertli D. Effect of the 50-hour workweek limitation on training of surgical residents in Switzerland. Arch Surg. 2010;145:558–63.
  31. Weiterbildungsstätten – qualitätsorientierte Kriterien. Swiss Medical Association (FMH) [homepage on the internet]; c2011 [cited 2011 Nov 20]. Available from: http://www.fmh.ch/files/pdf6/wbs_chirurgie.pdf.
  32. AQC Web site [homepage on the internet]; c2011 [cited 2011 Nov 20]. Available from: http://www.aqc.ch/Willkommen-bei-der-AQC.aspx.
  33. Poulose BK, Ray WA, Arbogast PG, et al. Resident work hour limits and patient safety. Ann Surg. 2005;241:847–56.
  34. Taffinder N. Better surgical training in shorter hours. J R Soc Med. 1999;92:329–31.
  35. Horne JA, Pettitt AN. High incentive effects on vigilance performance during 72 hours of total sleep deprivation. Acta Psychol (Amst). 1985;58:123–39.
  36. Haynes DF, Schwedler M, Dyslin DC, Rice JC, Kerstein MD. Are postoperative complications related to resident sleep deprivation? South Med J. 1995;88:283–9.
  37. Bartle EJ, Sun JH, Thompson L, Light AI, McCool C, Heaton S. The effects of acute sleep deprivation during residency training. Surgery. 1988;104:311–6.
  38. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–48.
  39. Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829–37.
  40. Warshaw AL, Sarr MG. The now and future world of restricted work hours for surgeons. Surgery. 2003;134:1–2.
  41. Ellman PI, Law MG, Tache-Leon C, Reece TB, Maxey TS, Peeler BB, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg. 2004;78:906–11.
  42. Kaafarani HM, Itani KM, Petersen LA, Thomby J, Berger DH. Does resident hours reduction have an impact on surgical outcomes? J Surg Res. 2005;126:167–71.
  43. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 1993;269:374–8.
  44. Groene O, Skau JK, Frølich A. An international review of projects on hospital performance assessment. Int J Qual Health Care. 2008;20:162–71.
  45. Dindo D, Hahnloser D, Clavien PA. Quality assessment in surgery: riding a lame horse. Ann Surg. 2010;251:766–71.
  46. Mache S, Kelm R, Bauer H, Nienhaus A, Klapp BF, Groneberg DA. General and visceral surgery practice in German hospitals: a real-time work analysis on surgeons’ work flow. Langenbecks Arch Surg. 2010;395(1):81–7.
  47. Macgregor JM, Sticca R. General surgery residents’ view on work hours regulations. J Surg Educ. 2010;67:376–80.
  48. Todd SR, Fahy BN, Paukert JL, Mersinger D, Johnson ML, Bass BL. How accurate are self-reported resident duty hours? J Surg Educ. 2010;67:103–7.
  49. Zuckerman JD, Kubiak EN, Immerman I, Dicesare P. The early effects of code 405 work rules on attitudes of orthopaedic residents and attending surgeons. J Bone Joint Surg Am. 2005;87(4):903–8.
  50. Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ. 2001;322:473–6.
  51. Paillaud E, Bories PN, Le Parco JC, Campillo B. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow up. Br J Nutr. 2000;83:97–103.
  52. Kanter G, Connelly NR, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg. 2006;103:1517–21.

Most read articles by the same author(s)