Am J Perinatol 2018; 35(09): 911-918
DOI: 10.1055/s-0038-1627442
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Association of Resident Duty Hour Restrictions, Level of Trainee, and Number of Available Residents with Mortality in the Neonatal Intensive Care Unit

Marc Beltempo*
1   Department of Neonatology, Montreal Children's Hospital, Montréal, Québec, Canada
Karin Clement*
2   Department of Pediatrics, CHU de Québec, Québec, Canada
Guy Lacroix
3   Department of Economics, Université Laval, Quebec, Canada
Sylvie Bélanger
4   Department of Neonatology, Université Laval, Québec, Canada
Anne-Sophie Julien
5   Department of Statistics, CHU de Québec Research Center, Québec, Canada
Bruno Piedboeuf
6   Department of Neonatology, Faculté de Médecine, Université Laval, Quebec, Canada
› Author Affiliations
Funding This study was supported by a grant from the Fédération des Médecins Résidents du Québec, Canada.
Further Information

Publication History

20 May 2017

04 January 2018

Publication Date:
08 February 2018 (online)


Objective This article assesses the effect of reducing consecutive hours worked by residents from 24 to 16 hours on yearly total hours worked per resident in the neonatal intensive care unit (NICU) and evaluates the association of resident duty hour reform, level of trainee, and the number of residents present at admission with mortality in the NICU.

Study Design This is a 6-year retrospective cohort study including all pediatric residents working in a Level 3 NICU (N = 185) and infants admitted to the NICU (N = 8,159). Adjusted odds ratios (aOR) were estimated for mortality with respect to Epoch (2008–2011 [24-hour shifts] versus 2011–2014 [16-hour shifts]), level of trainee, and the number of residents present at admission.

Results The reduction in maximum consecutive hours worked was associated with a significant reduction of the median yearly total hours worked per resident in the NICU (381 hour vs. 276 hour, p < 0.01). Early mortality rate was 1.2% (50/4,107) before the resident duty hour reform and 0.8% (33/4,052) after the reform (aOR, 0.57; 95% confidence interval [CI], 0.33–0.98). Neither level of trainee (aOR, 1.22; 95% CI, 0.71–2.10; junior vs. senior) nor the number of residents present at admission (aOR, 2.08; 95% CI, 0.43–10.02, 5–8 residents vs. 0–2 residents) were associated with early mortality. Resident duty hour reform was not associated with hospital mortality (aOR, 0.73; 95% CI, 0.50–1.07; after vs. before resident duty hour reform).

Conclusion Resident duty hour restrictions were associated with a reduction in the number of yearly hours worked by residents in the NICU as well as a significant decrease in adjusted odds of early mortality but not of hospital mortality in admitted neonates.

* Marc Beltempo and Karin Clement are co-primary authors.

Supplementary Material

  • References

  • 1 Bell BM. The new hospital code and the supervision of residents. N Y State J Med 1988; 88 (12) 617-619
  • 2 Philibert I, Nasca T, Brigham T, Shapiro J. Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?. Annu Rev Med 2013; 64: 467-483
  • 3 Nasca TJ, Day SH, Amis Jr ES. ; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363 (02) e3
  • 4 Bell EF, Hansen NI, Morriss Jr FH. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Impact of timing of birth and resident duty-hour restrictions on outcomes for small preterm infants. Pediatrics 2010; 126 (02) 222-231
  • 5 Rajaram R, Chung JW, Jones AT. , et al. Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. JAMA 2014; 312 (22) 2374-2384
  • 6 Patel MS, Volpp KG, Small DS. , et al. Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. JAMA 2014; 312 (22) 2364-2373
  • 7 Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005; 28 (11) 1392-1402
  • 8 Mansukhani MP, Kolla BP, Surani S, Varon J, Ramar K. Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature. Postgrad Med 2012; 124 (04) 241-249
  • 9 Parshuram CS, Amaral AC, Ferguson ND. , et al; Canadian Critical Care Trials Group. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ 2015; 187 (05) 321-329
  • 10 Landrigan CP, Rothschild JM, Cronin JW. , et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351 (18) 1838-1848
  • 11 Hugonnet S, Harbarth S, Sax H, Duncan RA, Pittet D. Nursing resources: a major determinant of nosocomial infection?. Curr Opin Infect Dis 2004; 17 (04) 329-333
  • 12 Dussault C, Saad N, Carrier J. 16-hour call duty schedules: the Quebec experience. BMC Med Educ 2014; 14 (Suppl. 01) S10
  • 13 Moore GP, Talarico S, Kempinska A, Lawrence SE, Weisz DE. An innovative on-call system for paediatric residency programs: the alternate night float. Paediatr Child Health 2015; 20 (02) 77-81
  • 14 Desai SV, Feldman L, Brown L. , et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med 2013; 173 (08) 649-655
  • 15 Castrodale V, Rinehart S. The golden hour: improving the stabilization of the very low birth-weight infant. Adv Neonatal Care 2014; 14 (01) 9-14
  • 16 Jensen EA, Lorch SA. Association between off-peak hour birth and neonatal morbidity and mortality among very low birth weight infants. J Pediatr 2017; 186: 41-48
  • 17 Aiken CE, Aiken AR, Scott JG, Brockelsby JC. The influence of hours worked prior to delivery on maternal and neonatal outcomes: a retrospective cohort study. Am J Obstet Gynecol 2016; 215 (05) 634.e1-634.e7
  • 18 Lee SK, Lee DS, Andrews WL, Baboolal R, Pendray M, Stewart S. ; Canadian Neonatal Network. Higher mortality rates among inborn infants admitted to neonatal intensive care units at night. J Pediatr 2003; 143 (05) 592-597
  • 19 Greenleaf EK, Aziz F, Hollenbeak CS. Operative autonomy among senior surgical trainees during infrainguinal bypass operations is not associated with worse long-term patient outcomes. Ann Vasc Surg 2017; 38: 42-53
  • 20 Sanders Jr RC, Giuliano Jr JS, Sullivan JE. , et al; National Emergency Airway Registry for Children Investigators and Pediatric Acute Lung Injury and Sepsis Investigators Network. Level of trainee and tracheal intubation outcomes. Pediatrics 2013; 131 (03) e821-e828
  • 21 Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors associated with adverse events during tracheal intubation in the NICU. Neonatology 2015; 108 (01) 23-29
  • 22 Sarnecki L, Gordon L. Analysis of acuity trends using Resource Intensity Weights via the CIHI Portal. Stud Health Technol Inform 2009; 143: 42-46
  • 23 Boukhris T, Sheehy O, Mottron L, Bérard A. Antidepressant use during pregnancy and the risk of autism spectrum disorder in children. JAMA Pediatr 2016; 170 (02) 117-124
  • 24 Joseph KS, Sheehy O, Mehrabadi A. , et al. Can drug effects explain the recent temporal increase in atonic postpartum haemorrhage?. Paediatr Perinat Epidemiol 2015; 29 (03) 220-231
  • 25 Monfared AA, Lelorier J. Accuracy and validity of using medical claims data to identify episodes of hospitalizations in patients with COPD. Pharmacoepidemiol Drug Saf 2006; 15 (01) 19-29
  • 26 Lemeshow S, Hosmer Jr DW. A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 1982; 115 (01) 92-106
  • 27 Canadian Medical Education Statistics. 2016. The Association of Faculties of Medicine of Canada; 2016. Available at: . Accessed March 1, 2017
  • 28 Morrison I, Flower D, Hurley J, McFadyen RJ. Working the night shift: a necessary time for training or a risk to health and safety?. J R Coll Physicians Edinb 2013; 43 (03) 230-235