Supporting the Challenges of Supporting the Challenges of Surgical Resident Training in the Surgical Resident Training in the

Era of Strict Duty-Hour Era of Strict Duty-Hour Compliance using an Integrated Compliance using an Integrated

Advanced Practitioner ModelAdvanced Practitioner Model

Randy Edwards, MD Randy Edwards, MD Department of Surgery Department of Surgery

Hartford HospitalHartford HospitalUniversity of Connecticut University of Connecticut

Integrated AP ModelIntegrated AP ModelDecember 16December 16thth, 2009 ACGME Letter, 2009 ACGME Letter

Two RRC anonymous survey citationsTwo RRC anonymous survey citationsCitation #1 – Continuous onsite dutyCitation #1 – Continuous onsite duty21% of residents revealed they had 21% of residents revealed they had worked more than worked more than

30 consecutive 30 consecutive hours – staying late or coming in earlyhours – staying late or coming in early

Citation #2 – Adequate time for restCitation #2 – Adequate time for rest29% of residents revealed they had not received 29% of residents revealed they had not received at least 10 hours off duty between shifts – rounds at least 10 hours off duty between shifts – rounds were were

consistently running late consistently running late

Integrated AP ModelIntegrated AP Model

Hartford Hospital General Surgery ServicesHartford Hospital General Surgery ServicesRed, Blue, and GreenRed, Blue, and Green3-4 residents per service with 1 AP3-4 residents per service with 1 APDaily Census – typically 25-30 patientsDaily Census – typically 25-30 patientsConsults 18-24 per dayConsults 18-24 per dayLate running OR cases (after 5pm) 2-3 rooms per dayLate running OR cases (after 5pm) 2-3 rooms per dayAfternoon Rounds Afternoon Rounds Chief or Senior resident dependentChief or Senior resident dependent Often starting after 6pmOften starting after 6pmAdvanced PractitionersAdvanced PractitionersNot integrated effectively – unclear expectationsNot integrated effectively – unclear expectationsAttendings not utilizing the APsAttendings not utilizing the APs

Integrated AP ModelIntegrated AP ModelDeadline and DiscussionsDeadline and Discussions

University of Connecticut - January 15University of Connecticut - January 15thth, 2010, 2010How do we control the duty hours ?How do we control the duty hours ?What happens to the resident paradigm ?What happens to the resident paradigm ?How many AP FTEs do we need ?How many AP FTEs do we need ?Who’s going to pay for the extra FTEs ?Who’s going to pay for the extra FTEs ?Should we cap the surgical services ?Should we cap the surgical services ?Do the residents have to cover Do the residents have to cover everyevery case ? case ?““Private” PA surgical service ?Private” PA surgical service ?How do we maintain quality care ?How do we maintain quality care ?

Integrated AP ModelIntegrated AP Model

Plan of Action given - UConn GMECPlan of Action given - UConn GMEC20 patient limit for each service20 patient limit for each serviceTemplated Call ScheduleTemplated Call ScheduleStrict adherence to the online duty hour Strict adherence to the online duty hour

reporting system – reporting system – zero tolerancezero toleranceAdd 1-2 APs to the Add 1-2 APs to the dailydaily OR coverage OR coverageMonday – Friday 11a-11p consult coverageMonday – Friday 11a-11p consult coverageAfternoon rounds start at 430pmAfternoon rounds start at 430pm““White Service” – Fourth General Surgery ServiceWhite Service” – Fourth General Surgery Service

Short stay and pathway patientsShort stay and pathway patients

Integrated AP ModelIntegrated AP Model

Three Advanced Practitioner ModelsThree Advanced Practitioner ModelsExtender ModelExtender Model

One or two APs working with team of residentsOne or two APs working with team of residentsNo appreciable benefit for duty hoursNo appreciable benefit for duty hours

Replacement ModelReplacement ModelAPs replace the entire resident team APs replace the entire resident team Mostly Physician AssistantsMostly Physician AssistantsICU coverageICU coverageFlexible OR assistance / consultsFlexible OR assistance / consultsProvide 24/7 coverageProvide 24/7 coverageAffects the duty hour compliance significantlyAffects the duty hour compliance significantly

Integration ModelIntegration Model

Integrated AP ModelIntegrated AP Model

Integration ModeIntegration ModellAdvanced PractitionersAdvanced Practitioners

SupplementSupplement the resident paradigm the resident paradigmProvideProvide OR, consult, and oncall coverage as needed OR, consult, and oncall coverage as neededFlexFlex into different resident roles into different resident rolesInterface with Attendings as neededInterface with Attendings as neededWeekday floor service rounds @ 430pmWeekday floor service rounds @ 430pmCoverCover Junior and Senior resident holes Junior and Senior resident holes Templated call schedule – days, nights, and holidaysTemplated call schedule – days, nights, and holidaysWell suited for PAs and APRNsWell suited for PAs and APRNsTremendous duty hour compliance gainsTremendous duty hour compliance gainsRequires accurate AP FTE resources and trainingRequires accurate AP FTE resources and training

Integrated AP ModelIntegrated AP Model

Integrated AP role and the “White” ServiceIntegrated AP role and the “White” ServicePlan of ActionPlan of ActionApproved - Hartford HospitalApproved - Hartford HospitalConditionally accepted - UConn GMECConditionally accepted - UConn GMECFebruary – October 2010February – October 2010 Added 8 new FTEs Added 8 new FTEs Total 17 AP FTEs Total 17 AP FTEs July 2010 – White Service startsJuly 2010 – White Service startsReplacement model Replacement model General Surgery Faculty acceptanceGeneral Surgery Faculty acceptanceChief - Senior resident concernsChief - Senior resident concernsGroup discussionsGroup discussionsMaintain the resident learning experienceMaintain the resident learning experience

Integrated AP ModelIntegrated AP Model

White ServiceWhite ServiceDaily coverage with two Advanced PractitionersDaily coverage with two Advanced PractitionersPathway and short stay patientsPathway and short stay patients

BariatricsBariatricsBreastBreastThyroid / ParathyroidThyroid / ParathyroidColorectal PathwayColorectal PathwayVentral / Incisional HerniaVentral / Incisional HerniaLaparoscopic Cholecystectomy/AppendectomyLaparoscopic Cholecystectomy/Appendectomy

Typical daily census 15-20 patientsTypical daily census 15-20 patientsAP Professional SatisfactionAP Professional Satisfaction

Integrated AP ModelIntegrated AP ModelBenefits of the Integrated AP ModelBenefits of the Integrated AP Model

Duty hour violations markedly reducedDuty hour violations markedly reducedNo negative resident impactNo negative resident impactSuccessful Quality CareSuccessful Quality CarePatient satisfaction maintainedPatient satisfaction maintainedImproved hospital discharge %Improved hospital discharge %No holes in the resident coverage/scheduleNo holes in the resident coverage/scheduleFlexible resident floor and OR coverageFlexible resident floor and OR coverageIntegrated education modelsIntegrated education modelsResourceful - defined Chief Resident supportResourceful - defined Chief Resident supportImproved OR charge captureImproved OR charge captureSurgical Faculty acceptance Surgical Faculty acceptance

Monthly Comparison # Residents in OR Monthly Comparison # Residents in OR

after 5 PMafter 5 PM

11stst Assist Quarterly Charges Assist Quarterly Charges

$28,243

$104,360

$144,117

$172,297

$208,782

$0

$50,000

$100,000

$150,000

$200,000

$250,000

FY 2010 OCT-DEC

FY 2010 JAN-MAR

FY 2010 APR-JUN

FY 2010 JUL-AUG

FY 2011 OCT-DEC

Patients Discharged Prior to 11 AMPatients Discharged Prior to 11 AM

24%

33%

0%

10%

20%

30%

FY 2010 OCT-JUN FY 2010 JULY-SEPT

HCAHPS SurveyHCAHPS Survey

Short Stay Patients

0%

20%

40%

60%

80%

100%

DoctorCommunication

Patient Advocacy(Likelihood toRecommend)

Overall HospitalExperience

Pre-Integration Post-Integration

HCAHPS SurveyHCAHPS Survey

Surgical Floor

0%

20%

40%

60%

80%

100%

DoctorCommunication

Patient Advocacy(Likelihood toRecommend)

Overall HospitalExperience

Pre-Integration Post-Integration

Integrated AP ModelIntegrated AP ModelResidents and APs need team approachResidents and APs need team approachShared patient responsibilities and learning Shared patient responsibilities and learning opportunitiesopportunitiesResident Education - supported using the AP Integration Resident Education - supported using the AP Integration ModelModelResidents still own their respective servicesResidents still own their respective servicesAPs still responsible to the Chief ResidentAPs still responsible to the Chief ResidentAPs need clear expectations APs need clear expectations The ability to flex into different resident rolesThe ability to flex into different resident rolesNeed adequate Attending supportNeed adequate Attending supportLimits the to assist with Chief Resident work hours Limits the to assist with Chief Resident work hours Overflow “White” service Overflow “White” service Provides a duty hour control mechanism Provides a duty hour control mechanism Helps to busy resident servicesHelps to busy resident servicesPromotes better hospital throughput Promotes better hospital throughput