Is it safe to have an ophthalmic emergency in July?
To deter-mine whether house staff experience affects the quality of acute ophthalmic care delivered in an emergency room at one teaching hospital.
The medical records of 360 patients who were seen by first-year ophthalmology residents in the Bascom Palmer Eye Institute emergency department were retrospectively reviewed. Records reviewed included 180 patients seen between July 15, 2002, and August 14, 2002 (the beginning of the training year), and 180 patients seen between June 1, 2003, and June 30, 2003 (the end of the training year).
The rate of unscheduled return visits to the emergency department at the beginning and end of the training year was 6.1% (11 of 180) and 5.0% (9 of 180), respectively (P = .82). Agreement between initial and final diagnoses occurred in 96% of patients (108 of 113) at the beginning of the training year and 98% of patients (84 of 86) at the end of the training year (P = .70).
There was no difference in the quality of medical care delivered by first-year ophthalmology residents at the beginning and end of the training year.
Available from: John Q Young
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ABSTRACT: It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year.
To systematically review studies describing the effects of trainee changeover on patient outcomes.
Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010.
Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator.
Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported.
Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results.
The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data.
Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic.
National Heart, Lung, and Blood Institute.
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Researchers have found mixed results about the risk to patient safety in July, when newly minted physicians enter U.S. hospitals to begin their clinical training, the so-called "July effect." However, patient and family satisfaction and perception of physician competence during summer months remain unknown.
The authors conducted a retrospective observational cohort study of 815 family members of adult intensive care unit (ICU) patients who completed the Family Satisfaction with Care in the Intensive Care Unit instrument from eight ICUs at Beth Israel Deaconess Medical Center, Boston, Massachusetts, between April 2008 and June 2011. The association of ICU care in the summer months (July-September) versus other seasons and family perception of physician competence was examined in univariable and multivariable analyses.
A greater proportion of family members described physicians as competent in summer months as compared with winter months (odds ratio [OR] 1.9; 95% confidence interval [CI] 1.2-3.0; P = .003). After adjustment for patient and proxy demographics, severity of illness, comorbidities, and features of the admission in a multivariable model, seasonal variation of family perception of physician competence persisted (summer versus winter, OR of judging physicians competent 2.4; 95% CI 1.3-4.4; P = .004).
Seasonal variation exists in family perception of physician competence in the ICU, but opposite to the "July effect." The reasons for this variation are not well understood. Further research is necessary to explore the role of senior provider involvement, trainee factors, system factors such as handoffs, or other possible contributors.
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