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High Hospital House Staff Workload Associated With Worse Patient Outcomes

A heavier workload for hospital residents on patient admission days was associated with increased length of hospital stay, total costs and risk of inpatient death//, according to a report in the issue of the Archives of Internal Medicine.

New duty-hour reduction requirements for house staff—the group of resident physicians at a hospital who are receiving additional training in a specialty under the supervision of an attending specialist—have led to substantial changes in residency team structures, according to background information in the article. Ideally, these changes would improve or have no effect on patient outcomes—such as death, readmission, length of stay and total costs. However, there are few studies that address these topics.

Michael Ong, M.D., Ph.D., of the University of California, Los Angeles, and colleagues conducted a retrospective analysis to determine the association between house staff workload on a patient’s day of admission or on subsequent hospital days and patient outcomes. They analyzed data on 5,742 adults who were admitted to the General Medicine Service at the University of California, San Francisco’s Moffitt-Long Hospital between July 1, 1998, and June 30, 2001.

The authors found that two different measures of the hospital residents’ workload were significantly associated with patient outcomes. Each additional admission by a residency team increased the length of stay, total costs and risk of dying in the hospital for each patient who was admitted on that day—risks that increased even more substantially when the team admitted more than nine patients. “Our findings suggest that higher house staff workload on admitting days—when fewer backup resources are available—increases resource use and may increase inpatient mortality,” they write.

“Conversely, a higher average team census was associated with reduced resource use, perhaps reflecting service-level adaptations to workload,” they continue. Each additional patient that the residency team cared for during a patient’s hospitalization decreased the patient’s length of stay and total costs, with the most marked reductions occurring when the average census was more than 15 patients.

The authors suggest that in an era when hospital organizational structures are in considerable flux, further studies are required to prospectively determine the impact of house staff team workload and organization on patient outcomes.

“Programs seeking to minimize total costs and lengths of stay may want to find ways to reduce team admission loads, while maximizing availability of other resources on non-admitting days,” they write.

“Balancing the clinical and economic outcomes with available resources and the educational impact of changes in the organization of house staff teams will be important tasks for training programs and teaching hospitals in coming years,” they conclude.

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