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Restructuring an Inpatient Resident Service to Improve Outcomes for Residents, Students, and Patients. O'Connor AB, Lang VJ, Bordley DR. Academic Medicine 2011; 86(12):1500-1507.


Reviewed by Kyra A. Len

What was the study question?
Would restructuring a resident teaching service have an effect on resident, student and patient outcomes?

How was the study done?
The setting was a 750 bed tertiary care teaching hospital on the east coast involving an internal medicine residency program. The program was restructured in 2008. Restructuring involved eliminating the "day float" admitting team and converting the one resident-one intern teams to one resident-two intern teams, thereby reducing intern caps from 11 to 7 patients and increasing the paring between resident teams and attendings. Their outcome measures were end-of-rotation evaluation forms for residents and students, random paging activity logs, patient logs and medicine subject exam scores. For the random paging logs the residents and interns were randomly paged during the day and logged what they were doing at the time (writing notes, teaching, with the patients, etc.). They compared these outcome measures for the 2007-2008 class (pre-restructuring) and 2008-2009 class (post-restructuring). They also evaluated hospital-collected patient outcome data.

What were the results?
Post-restructuring the rotation significantly improved the residents' and interns' overall rotation enjoyment (mean change 0.35, p<.001 and 0.19, p =0.04 respectively). Other rotation scores were similar in the intern and resident evaluations. After restructuring, the residents spent more time in direct patient care activities (38.1% of time vs. 22.8% or time, p=0.002) and with interns (45.3% of time vs. 34.2% of time, p = 0.49), but less time with medical students (24.1% of time vs. 36.6% of time, p=0.02). The interns also spent less time with medical students at the time of random paging (25.2% down from 33.1%, p=0.03).The medical students were noted to rate rounds with ward attending and the accessibility of the teachers/faculty higher in their clerkship evaluation post-restructuring. Medicine exam scores were similar in both years. Patient outcomes were notable for an increase in hospitalist-attended residents' patients, decrease in median length of stay (5.0 to 4.0 days, p=0.02) and fewer patients requiring the ICU (11.2% to 7.9%, p<0.001). Press Ganey survey results post-restructuring were similar.

What are the implications of these findings?
The authors note that by restructuring their medicine rotation to involve less hand-offs, decreasing the intern patient census and increasing hospitalist pairing with resident teams, they found improvement in resident satisfaction, student satisfaction and a favorable impact on patient outcomes. This study implicates that by improving continuity of care for patients by eliminating a "day float" team and lowering the intern cap that there is overall improvement in patient care and resident satisfaction. The reflected improvement on the medicine clerkship rotation was also interesting considering that both the interns and residents were noted to be spending less time with medical students at the time of the random page. The authors attribute that the students' increased contact with faculty and increased satisfaction with attending rounds was due to the teams being aligned with a single attending.

Editor's note: This study's setting was internal medicine. Would similar results be found in pediatrics? This study presents a no cost method to improve education and highlights the importance of caring for - and thinking about - patients from admission through to discharge. (SLB)

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