Duty hours and paper records

Summaries from ACP Hospitalist Weekly.

Flexible duty-hour policies associated with higher dissatisfaction among interns

Internal medicine interns in programs with flexible duty-hour policies were less satisfied with their educational experience than those in programs with standard policies, according to findings from the Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial.

Researchers compared two duty-hour configurations: the standard policies adopted in 2011 by the Accreditation Council for Graduate Medical Education (ACGME) and more flexible policies that did not limit shift length or specify mandatory time off between shifts. They randomized 63 U.S. internal medicine residency programs to implement either the ACGME policies (n=31) or flexible policies (n=32).

From July 1, 2015, to June 30, 2016, researchers compared the groups on a variety of measures. Primary outcomes were interns' direct patient care and educational activities (assessed by observation), trainee and faculty satisfaction with education (assessed by survey), and interns' medical knowledge (assessed by score on the ACP In-Training Examination). Results on patient mortality outcomes, assessed using 2015 and 2016 Medicare data, are not yet available.

Results were published online on March 20 by the New England Journal of Medicine and appeared in the April 19 issue.

There were no significant differences between groups in the mean percentages of time that interns spent on direct patient care and education. In addition, there were no significant differences in trainees' reported perceptions of an appropriate balance between clinical work and education (response rate, 91%) or faculty members' assessments of whether trainees' workload exceeded their capacity (response rate, 90%).

Another survey (response rate, 49%) found that interns in flexible programs were more likely than those in standard programs to report dissatisfaction with various training aspects (odds ratio, 1.67; 95% CI, 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). However, in a faculty survey (response rate, 98%), directors of flexible programs were less likely than those of standard programs to report dissatisfaction with various educational processes (odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average test scores were 68.9% in flexible programs and 69.4% in standard programs, a difference which did not meet the noninferiority margin of two percentage points.

An accompanying editorial noted limitations to the study, such as limited generalizability, desirability bias in residents' survey responses, low response rates to some elements, substantial variations in outcomes between programs, and difficulties characterizing the actual differences in hours worked between groups. In addition, flexible programs applied that flexibility to a small minority of trainees' rotations, the editorialist noted.

According to the editorial, the iCOMPARE results represent a “sentinel plea of residents to reform our clinical learning environments to prioritize people,” since more than two-thirds of all respondents reported high or moderate levels of burnout (i.e., emotional exhaustion, depersonalization, and low perceptions of personal accomplishment).

Paper records containing personal information not always properly discarded by hospitals

Hospitals may not always properly dispose of paper records containing personal information, according to a research letter.

Researchers performed a recycling audit at five teaching hospitals in Toronto to determine the presence, amount, and sensitivity of personally identifiable information and personal health information. Recycling at each hospital was collected at least three times a week for four weeks from locations including inpatient wards, outpatient clinics, physician offices, ICUs, and EDs.

Photo by Thinkstock
Photo by Thinkstock.

Personally identifiable information was defined as information that identifies an individual or could reasonably be used alone or with other information to identify an individual. Personal health information was defined as personally identifiable information plus information related to medical care. Recovered items were classified by potential sensitivity as low, medium, or high sensitivity. Results were published March 20 by JAMA.

The researchers recovered a total of 591.6 kg of recycling, which included 2,687 documents containing personally identifiable information. Of these, 802 contained information of low sensitivity, 843 contained information of medium sensitivity, and 1,042 contained information of high sensitivity. All hospitals had personally identifiable information or personal health information found in their recycling bins, with physician offices being the most common location (1,449 of 2,687 items). The most frequent types of improperly discarded personally identifiable information were clinical notes, summaries, and medical reports.

The study looked only at recycling and did not look at garbage, the authors noted. They also pointed out that there was no way to tell whether patients or staff had discarded items and that to their knowledge no inappropriate use or harm has been reported due to this type of data breach. However, they stressed that the move to electronic health records may lead to increased disposal of paper charts, which in turn may increase the risk of inappropriate handling of personal information.

“Elimination of any alternatives to nonconfidential disposal of discarded paper (irrespective of content) in areas of clinical activity may be an effective, albeit expensive strategy to reduce the risks of paper-based privacy breaches,” the authors wrote. “Minimizing the printing of documents containing [personal health information] would be a complementary approach.”