Exploring the relationship between resident education, discontinuity of care and patient outcomes

1. Exploring the relationship between resident education, discontinuity of care and patient outcomes Kathlyn E. Fletcher, MD MA July 13, 2005

2. Piglet is entirely surrounded by water Then suddenly he remembered a story which Christopher Robin had told him about a man on a desert island who had written something in a bottle and thrown it in the sea; and Piglet thought that if he wrote something in a bottle and threw it in the water, perhaps somebody would come and rescue him! He left the window and began to search his house, all of it that wasn't under water, and at last he found a pencil and a small piece of dry paper, and a bottle with a cork to it. And he wrote on one side of the paper: HELP! PIGLET (ME) and on the other side: IT'S ME PIGLET, HELP HELP! Then he put the paper in the bottle, and he corked the bottle up as tightly as he could, and he leant out of his window as far as he could lean without falling in, and he threw the bottle as far as he could throw -- splash! -- and in a little while it bobbed up again on the water; and he watched it floating slowly away in the distance, until his eyes ached with looking, and sometimes he thought it was the bottle, and sometimes he thought it was just a ripple on the water which he was following, and then suddenly he knew that he would never see it again and that he had done all that he could do to save himself. AA Milne

3. HELP! Kathlyn (ME) IT'S ME Kathlyn, HELP HELP!

4. Background • Resident work hours rules went into effect on July 1, 2003 • Patient safety (because of fatigue-related errors) cited as a major motivator • Many are concerned about continuity of care leading to errors • Simply reducing hours will not necessarily result in improved patient safety

5. Quick Summary of Research in the Field • Single institutional studies • Few evaluated patient outcomes • RCTs (well, one anyway) • Single institution • Observational or pre-post • Lots of unvalidated survey studies

6. Topics for this session • Conceptual Model • Study Questions and Hypothesis • Study Methods • Composition of study group • Measurement suggestions • Analysis suggestions

7. Building the Model: 1Resident-perceived contributors to patient care errors • Rules as a goal • Workload • Entropy • Fatigue • Inexperience • Sign-out • Not knowing patients • Night time

8. Building a conceptual model: 1 Contributors to quality and safety of patient care by residents • Experience-inexperience • Disease-specific • Procedural • Medical knowledge acquisition Supervision Knowledge of patient-specific information Responsibility within team/ Ownership • Workload/ Entropy • Primary work • Cross-cover work

9. Building the Model:2The ACGME work hour rules • No more than 80 hours/week (averaged over 4 weeks) • No more than 24 hours in a row + 6 for hand-offs, didactics (“24+6” rule) • One day off per week (averaged over 4 weeks) • 10 hours free from duty after each shift

10. Building a conceptual model -2 Contributors to quality and safety of patient care by residents Effects of interventions to comply with work hour rules • Experience-inexperience • Disease-specific • Procedural • Medical knowledge acquisition Discontinuity / hand-offs Fewer hours of training Supervision Knowledge of patient-specific information Responsibility within team/ Ownership • Workload/ Entropy • Primary work • Cross-cover work

11. Building the Model: 3Patient-centered outcomes • Process measures • Easier to measure • Larger n • Important if linked to actual outcomes • Clinical outcomes • Hospital Mortality • Morbidity? Disease specific, ?QOL-SF 36 • Adverse events

12. Selected contributors to quality and safety of patient care by residents Selected effects of interventions to comply with work hour rules • Experience-inexperience • Disease-specific • Procedural • Medical knowledge acquisition Discontinuity / hand-offs Fewer hours of training Patient-centered outcomes • Process-of-care • Quality of care • Errors • Clinical outcomes • Adverse events • Mortality • Morbidity Supervision Knowledge of patient-specific information Responsibility within team Workload Conceptual model-3

13. Research questions • How do resident experience and medical knowledge impact patient care? • How does discontinuity mediate these relationships? • How does patient-specific knowledge impact patient care? • How does discontinuity mediate this relationship? • How does sense of responsibility impact patient care? • How does discontinuity mediate this relationship?

14. Hypotheses • Resident experience and knowledge are positively related to patient care outcomes. • Discontinuity negatively impacts resident experience. • Greater patient-specific knowledge results in better patient care • Discontinuity negatively impacts patient-specific knowledge • Feeling responsible for patients is related to patient care outcomes. • Discontinuity negatively impacts sense of responsibility for patients.

15. Primary Aims • Measure resident disease-specific experience and knowledge acquisition and compare those to patient outcomes. • Determine how discontinuity mediates the relationships. • Measure patient-specific knowledge (or at least perceived patient-specific knowledge) and compare that to patient outcomes. • Determine how discontinuity mediates the relationship. • Measure perceived sense of responsibility for patients and compare that to patient outcomes. • Determine how discontinuity mediates the relationship.

16. Secondary Aims • Develop a valid, reliable method for measuring discontinuity • Quantitative • Descriptive (e.g. discontinuity between admission to the rest of hospitalization) • Develop a tool for measuring perceived patient specific knowledge • Develop a tool for measuring perceived individual responsibility

17. Methods Study design Prospective cohort study of 1 internal medicine intern class at our institution for 1 year -approximately 40 interns -approximately 21 categorical interns Followed at VA and FMLH

18. Proposed measurement tools

19. Measurement tools

20. Measurement tools Admitted by I=primary intern, R=primary resident, N=non-team member, O=other (explain) A= admitted, D=discharged, M=died (mortality), T=transferred (I=ICU, S=surgical service, O=other (explain))

21. Measurement tools

22. Proposed analyses

23. Timeline

24. Specific points for feedback • Other important components of the model? • Size/composition of cohort? • Methods/measurements suggestions?