Amelioration of increased intensive care unit service readmission rate after implementation of work-hour restrictions

In July 2003, we reallocated our resident workforce to address mandated duty-hour restrictions. In the subsequent academic year (AY), surgical intensive care unit (SICU) service readmission rates (RR) doubled. We hypothesized that a targeted intervention could reduce SICU service RR in academic year (AY) 2004-05.

This study was conducted at an urban teaching hospital before (AY02-03, period 1), during (AY03-04, period 2), and after (AY04-05, period 3) implementation of the Accreditation Council for Graduate Medical Education guidelines. Demographics, RR, and reason were culled from Project Impact and a complications database. SICU staff (dedicated intensivist, two or three fellows, and six residents) remained constant. In periods 2 and 3 (versus 1), ward residents cross-covered > or = 3 services every 5 to 6 nights (versus every 3 in period 1) with physician assistant support (versus none in period 1). During period 3, a focused transfer phone call, charted care summary, and discharge checkup defined the intervention. Interperiod comparisons were by chi2 and t test analysis; p < 0.05 (versus period 1) defined significance.

In all, 1,570, 1,705 and 1,681 patients were treated in periods 1, 2, and 3, respectively. There were no demographic or APACHE score differences. RRs were 1.4%, 3.0% and 1.2% in periods 1, 2, and 3, respectively. The percentages of readmissions as a result of ward care were 16.7, 41, and 10%, respectively. The most common readmission indication was respiratory (46% in period 1; 51% in period 2, and 80% in period 3) and was associated with an increased proportion of readmission as a result of patient disease (46% in period 1; 41% in period 2; 80% in period 3). Intervention noncompliance preceded 30% of period 3 readmissions.

A targeted intervention can reduce the rate of SICU readmission caused by care inadequacies stemming from a resident reallocation strategy.