Where: Strong Memorial Hospital, the 750-bed, tertiary care teaching hospital for the University of Rochester in New York.
The issue: Reducing pressure on overworked residents.
Before 2008, the University of Rochester had a relatively unusual structure for its residency service. Each resident was paired with a single intern, and these pairs cared for a maximum of 11 patients for various hospitalists, primary care doctors, and subspecialty attendings. Under the time pressure of reduced work-hour limits, the system was drawing some complaints.
“We were hearing from our residents that they were having a lot of trouble getting their work done during the course of the day, because the patient complexity and volume that they were dealing with was too high, and also the discontinuity between different providers,” said Alec B. O’Connor, MD, MPH, FACP, associate professor and associate director of the internal medicine residency. In response to these concerns, Dr. O’Connor and colleagues decided to try a new setup for the 2008-2009 residency year.
How it works
Under the new system, each resident led two interns, each of whom had a patient cap of seven. (Two interns were shifted from other rotations to fill the teams.) Each team was also assigned to a specific hospitalist, who served as the attending for all the team's patients, and an effort was made to focus the resident service's assignments on hospitalist patients, rather than patients cared for by other physicians.
The team's hospitalist also led daily combined work and teaching rounds. In the old system, one hospitalist had led the team on work rounds three times a week while another did twice weekly case conferences.
“It was a big culture change here. In order to restructure the teams the way we wanted to, we had to move away from what had been traditionally a University of Rochester mainstay, that was the one resident, one intern pairing,” said Dr. O’Connor. “People had really felt it was an important part of what they liked about being here as a resident. It was a leap of faith.”
The leap appears to have paid off. In results published in the December 2011 Academic Medicine, residents and interns were surveyed after a year of the new system, and they reported significantly greater enjoyment of their rotations. Students also rated parts of their experiences more highly and had the chance to perform the first evaluation of more patients.
The new teams cared for more patients overall, while the number of patients each intern saw per day dropped from 9.9 to 6.3. The increase in the teaching service's capacity allowed the nonteaching service to reduce its staffing by one nonphysician provider per day.
“We did see slight increases in the amount of time residents were spending with patients,” added Dr. O’Connor. “We were expecting to see a bigger change in that….Maybe we were overly optimistic in what we were hoping for.”
How patients benefit
The study did find statistically significant improvements in other markers affecting patients. Between the 2007-2008 and 2008-2009 residency years, the median length of stay decreased from five days to four and fewer patients required intensive care (7.9% instead of 11.2%).
“We don't know if those differences were caused by the intervention or coincidental,” said Dr. O’Connor. “But they're certainly interesting and may well have been related to the intervention, which did reduce the number of handoffs and improved coordination—and likely communication—between residents and attendings.”
The new system did require a few more handoffs among attending hospitalists, because patients who were admitted in the evening by a night float resident and a hospitalist working at the time could be transferred to a resident team and its attached hospitalist in the morning.
“That was relatively infrequent,” said Dr. O’Connor. “In general, the faculty really enjoyed having a larger percentage of their patients with one team. They could coordinate better. They could round together and communication was a whole lot easier.”