Extended-Duration Work Shifts in Surgical Specialties: A Systematic Review.

INTRODUCTION: There has been widespread international implementation of duration-hour restrictions to prevent surgical resident burnout and promote patient safety and wellbeing of doctors. A variety of Extended-Duration Work Shifts (EDWS) have been implemented, with a variety of studies examining the effect of shift systems on both surgical performance and the stress response unestablished in the literature. METHODS: This was a systematic review evaluating the impact of extended working hours on surgical performance, cognitive impairment, and physiological stress responses. The review used PubMed, Ovid Medline, Embase, and Google Scholar search engines between September and October 2021 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters including studies carried out after 2002 and published in the English language were applied. RESULTS: In total, 30 studies were included for analysis. General surgery was the most commonly studied rotation, with Neurosurgical, Orthopedic, and ear, nose and throat specialties also included. The majority of studies found no difference or a significant improvement in post-EDWS on simulated performance. EDWS appeared to have the greatest impact on physiological stress markers in junior surgical trainees. CONCLUSIONS: Experience appears to confer a protective element in the postcall period, with preservation of skill demonstrated. More experienced clinicians yielded lower levels of physiological markers of stress, although variability in hierarchical workload should be considered. Heterogeneity of findings across physiological, cognitive, and psychomotor assessments highlights the need for robust research on the optimum shift pattern prevents worker burnout and promotes patient safety. Future research to evaluate correlation between stress, on-call workload, and performance in the postcall period is warranted.

Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit.

BACKGROUND: In Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications. METHODS: An adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding. RESULTS: Overall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 . CONCLUSION: This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.