Bailit Jennifer L, Blanchard May Hsieh
Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio 44109-1998, USA.
Obstet Gynecol. 2004 Apr;103(4):613-6. doi: 10.1097/01.AOG.0000119225.57285.c1.
To measure the effect of house staff working hours reforms on the quality of obstetric and gynecologic care.
Sentinel events, medication errors, maternal and neonatal outcomes, and decision making were measured before and after the Accreditation Council of Graduate Medical Education work-hour reforms. Data sources consisted of the perinatal database at MetroHealth Medical Center (Case Western Reserve University, Cleveland, OH), incident reports filed in the hospital department of risk management, the patient-satisfaction database at MetroHealth Medical Center, and the pharmacy medication error database. Two reviewers examined all incident reports separately, and discrepancies were resolved by mutual agreement.
Patient demographics did not change across the 2 time periods. Obstetric outcomes were the same for third- and fourth-degree lacerations, umbilical arterial pH less than 7, fever, and the need for general anesthesia. Postpartum hemorrhage and neonatal resuscitations were significantly decreased over time (2% before versus 1% after work-hour restrictions [P =.008], and 30% before versus 26% after work-hour restrictions [P <.001], respectively). The rate of primary cesarean delivery rose from 14% to 16%, a nonsignificant difference (P <.06). There were no differences in rates of cesarean delivery for nonreassuring fetal status, failed induction, labor abnormality, or repeat cesarean delivery. Reported medication errors associated with resident performance were too rare for comparison across time periods. The number of incident reports directly involving residents before and after work-hour restrictions were 3 and 10, respectively-too few to reach statistical significance.
Although problems in physician performance may be underreported, resident work-hour restrictions show minimal evidence of improvement in quality of care.
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评估住院医师工作时间改革对妇产科护理质量的影响。
在研究生医学教育认证委员会工作时间改革前后，对警讯事件、用药错误、孕产妇和新生儿结局以及决策制定情况进行评估。数据来源包括地铁健康医疗中心（凯斯西储大学，俄亥俄州克利夫兰）的围产期数据库、医院风险管理部门提交的事件报告、地铁健康医疗中心的患者满意度数据库以及药房用药错误数据库。两名审阅者分别检查所有事件报告，分歧通过双方协商解决。
两个时间段的患者人口统计学特征未发生变化。三度和四度会阴裂伤、脐动脉血pH值低于7、发热以及全身麻醉需求方面的产科结局相同。随着时间推移，产后出血和新生儿复苏显著减少（工作时间限制前为2%，之后为1%[P = 0.008]；工作时间限制前为30%，之后为26%[P < 0.001]）。首次剖宫产率从14%升至16%，差异无统计学意义（P < 0.06）。胎儿状况不令人放心、引产失败、产程异常或再次剖宫产的剖宫产率无差异。与住院医师表现相关的报告用药错误太少，无法在不同时间段进行比较。工作时间限制前后直接涉及住院医师的事件报告数量分别为3份和10份，数量太少，无法达到统计学意义。
尽管医师表现方面的问题可能报告不足，但住院医师工作时间限制显示出护理质量改善的证据极少。
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