New ACGME-Compliant Staffing Model Cuts Hospital Costs

GRAPEVINE, TEX. – July brings more restrictions on resident duty hours, but compliance with these requirements can result in reduced hospitalization costs and shorter lengths of stay, if it’s done right.

A study by hospitalists at the University of California, San Francisco’s Benioff Children’s Hospital that analyzed their attempt to cut resident work hours by enlarging care teams and eliminating cross coverage found that a new staffing model reduced hospitalization costs by about 11% and length of stay by about 18%.

Starting July 1, new resident duty-hours requirements from the ACGME (Accreditation Council for Graduate Medical Education) will go into effect, eliminating long shifts for interns. Specifically, interns (PGY-1 residents) will no longer be able to work 30-hour shifts, but will be limited to shifts of no more than 16 hours.

In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams.

The goal was to increase "patient ownership" by reducing handoffs and to improve patient care by having a more consistent provider overnight, said Dr. Glenn Rosenbluth, a pediatric hospitalist at the hospital. He presented the study results at the annual meeting of the Society of Hospital Medicine.

"The idea was that a resident working a 30-hour shift at 2 in the morning might be more focused on just urgent issues, calls from the nurses, and potentially seeing the call room when they get some down time, whereas someone working a week of dedicated night shifts might be more awake and more interested in advancing care because they’re a member of the primary team," he said.

Prior to September 2008, general pediatrics patients were covered by house-staff teams comprising two interns and one senior resident who were working shifts of up to 30 hours. The interns took call every sixth night and senior residents took call every fifth night. They provided cross-coverage of patients on multiple teams at night. Generally, this meant that one team was working each night and covering for all other teams, Dr. Rosenbluth said.

After the reorganization, they expanded the house-staff teams to four interns per team, with each intern working 3 weeks of day shift and 6 consecutive night shifts. The shifts were generally about 13 hours. The changes allowed them to eliminate cross-coverage and to have a dedicated night team. The attending coverage by hospitalists was unchanged.

To study the impact of the new staffing model, the researchers performed a retrospective, interrupted time series cohort study using concurrent controls. The target group was children who were admitted to the hospital’s general pediatric service. The concurrent control group consisted of surgical patients who were admitted to the same inpatient unit.

Using administrative billing data from the medical center, they analyzed hospitalization costs and length of stay for children who were admitted to the pediatric medical-surgical unit from Sept. 15, 2007, through Sept. 15, 2009. The researchers analyzed data on 280 patients before intervention and 274 patients after intervention. They excluded patients who had spent any time in the pediatric ICU and patients who were on specialty services not covered by either a pediatric hospitalist or a general surgeon. The researchers used multivariate models to adjust for age, sex, the season of year, the admitting diagnosis, and any clustering at the attending level.

They found that for general pediatric patients who were admitted to the medical-surgical unit there was an adjusted rate ratio of 0.82 for length of stay following the intervention. That was an 18% decrease in length of stay from before the intervention. Similarly, hospitalization costs had an adjusted rate ratio of 0.89, an 11% decrease from before the intervention. Among the surgery patients who acted as the control group, there was no statistically significant change in the length of stay and there was a small increase in the cost of hospitalization.

Although there may be incremental costs associated with making the staffing changes needed to comply with the new ACGME duty-hours requirements, Dr. Rosenbluth said the study suggests that these costs may be partially offset by improved care efficiency.

But Dr. Rosenbluth acknowledged that the study did have some limitations. The biggest issue is the limited ability to disentangle the impact of scheduling changes from other changes that were occurring on the unit at the same time. "There was a lot going on, as is the case on all of our units," he said.

The authors reported no disclosures.

GRAPEVINE, TEX. – July brings more restrictions on resident duty hours, but compliance with these requirements can result in reduced hospitalization costs and shorter lengths of stay, if it’s done right.

A study by hospitalists at the University of California, San Francisco’s Benioff Children’s Hospital that analyzed their attempt to cut resident work hours by enlarging care teams and eliminating cross coverage found that a new staffing model reduced hospitalization costs by about 11% and length of stay by about 18%.

Starting July 1, new resident duty-hours requirements from the ACGME (Accreditation Council for Graduate Medical Education) will go into effect, eliminating long shifts for interns. Specifically, interns (PGY-1 residents) will no longer be able to work 30-hour shifts, but will be limited to shifts of no more than 16 hours.

In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams.

The goal was to increase "patient ownership" by reducing handoffs and to improve patient care by having a more consistent provider overnight, said Dr. Glenn Rosenbluth, a pediatric hospitalist at the hospital. He presented the study results at the annual meeting of the Society of Hospital Medicine.

"The idea was that a resident working a 30-hour shift at 2 in the morning might be more focused on just urgent issues, calls from the nurses, and potentially seeing the call room when they get some down time, whereas someone working a week of dedicated night shifts might be more awake and more interested in advancing care because they’re a member of the primary team," he said.

Prior to September 2008, general pediatrics patients were covered by house-staff teams comprising two interns and one senior resident who were working shifts of up to 30 hours. The interns took call every sixth night and senior residents took call every fifth night. They provided cross-coverage of patients on multiple teams at night. Generally, this meant that one team was working each night and covering for all other teams, Dr. Rosenbluth said.

After the reorganization, they expanded the house-staff teams to four interns per team, with each intern working 3 weeks of day shift and 6 consecutive night shifts. The shifts were generally about 13 hours. The changes allowed them to eliminate cross-coverage and to have a dedicated night team. The attending coverage by hospitalists was unchanged.

To study the impact of the new staffing model, the researchers performed a retrospective, interrupted time series cohort study using concurrent controls. The target group was children who were admitted to the hospital’s general pediatric service. The concurrent control group consisted of surgical patients who were admitted to the same inpatient unit.

Using administrative billing data from the medical center, they analyzed hospitalization costs and length of stay for children who were admitted to the pediatric medical-surgical unit from Sept. 15, 2007, through Sept. 15, 2009. The researchers analyzed data on 280 patients before intervention and 274 patients after intervention. They excluded patients who had spent any time in the pediatric ICU and patients who were on specialty services not covered by either a pediatric hospitalist or a general surgeon. The researchers used multivariate models to adjust for age, sex, the season of year, the admitting diagnosis, and any clustering at the attending level.

They found that for general pediatric patients who were admitted to the medical-surgical unit there was an adjusted rate ratio of 0.82 for length of stay following the intervention. That was an 18% decrease in length of stay from before the intervention. Similarly, hospitalization costs had an adjusted rate ratio of 0.89, an 11% decrease from before the intervention. Among the surgery patients who acted as the control group, there was no statistically significant change in the length of stay and there was a small increase in the cost of hospitalization.

Although there may be incremental costs associated with making the staffing changes needed to comply with the new ACGME duty-hours requirements, Dr. Rosenbluth said the study suggests that these costs may be partially offset by improved care efficiency.

But Dr. Rosenbluth acknowledged that the study did have some limitations. The biggest issue is the limited ability to disentangle the impact of scheduling changes from other changes that were occurring on the unit at the same time. "There was a lot going on, as is the case on all of our units," he said.

The authors reported no disclosures.

GRAPEVINE, TEX. – July brings more restrictions on resident duty hours, but compliance with these requirements can result in reduced hospitalization costs and shorter lengths of stay, if it’s done right.

A study by hospitalists at the University of California, San Francisco’s Benioff Children’s Hospital that analyzed their attempt to cut resident work hours by enlarging care teams and eliminating cross coverage found that a new staffing model reduced hospitalization costs by about 11% and length of stay by about 18%.

Starting July 1, new resident duty-hours requirements from the ACGME (Accreditation Council for Graduate Medical Education) will go into effect, eliminating long shifts for interns. Specifically, interns (PGY-1 residents) will no longer be able to work 30-hour shifts, but will be limited to shifts of no more than 16 hours.

In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams.

The goal was to increase "patient ownership" by reducing handoffs and to improve patient care by having a more consistent provider overnight, said Dr. Glenn Rosenbluth, a pediatric hospitalist at the hospital. He presented the study results at the annual meeting of the Society of Hospital Medicine.

"The idea was that a resident working a 30-hour shift at 2 in the morning might be more focused on just urgent issues, calls from the nurses, and potentially seeing the call room when they get some down time, whereas someone working a week of dedicated night shifts might be more awake and more interested in advancing care because they’re a member of the primary team," he said.

Prior to September 2008, general pediatrics patients were covered by house-staff teams comprising two interns and one senior resident who were working shifts of up to 30 hours. The interns took call every sixth night and senior residents took call every fifth night. They provided cross-coverage of patients on multiple teams at night. Generally, this meant that one team was working each night and covering for all other teams, Dr. Rosenbluth said.

After the reorganization, they expanded the house-staff teams to four interns per team, with each intern working 3 weeks of day shift and 6 consecutive night shifts. The shifts were generally about 13 hours. The changes allowed them to eliminate cross-coverage and to have a dedicated night team. The attending coverage by hospitalists was unchanged.

To study the impact of the new staffing model, the researchers performed a retrospective, interrupted time series cohort study using concurrent controls. The target group was children who were admitted to the hospital’s general pediatric service. The concurrent control group consisted of surgical patients who were admitted to the same inpatient unit.

Using administrative billing data from the medical center, they analyzed hospitalization costs and length of stay for children who were admitted to the pediatric medical-surgical unit from Sept. 15, 2007, through Sept. 15, 2009. The researchers analyzed data on 280 patients before intervention and 274 patients after intervention. They excluded patients who had spent any time in the pediatric ICU and patients who were on specialty services not covered by either a pediatric hospitalist or a general surgeon. The researchers used multivariate models to adjust for age, sex, the season of year, the admitting diagnosis, and any clustering at the attending level.

They found that for general pediatric patients who were admitted to the medical-surgical unit there was an adjusted rate ratio of 0.82 for length of stay following the intervention. That was an 18% decrease in length of stay from before the intervention. Similarly, hospitalization costs had an adjusted rate ratio of 0.89, an 11% decrease from before the intervention. Among the surgery patients who acted as the control group, there was no statistically significant change in the length of stay and there was a small increase in the cost of hospitalization.

Although there may be incremental costs associated with making the staffing changes needed to comply with the new ACGME duty-hours requirements, Dr. Rosenbluth said the study suggests that these costs may be partially offset by improved care efficiency.

But Dr. Rosenbluth acknowledged that the study did have some limitations. The biggest issue is the limited ability to disentangle the impact of scheduling changes from other changes that were occurring on the unit at the same time. "There was a lot going on, as is the case on all of our units," he said.

The authors reported no disclosures.