Rate of undesirable events at beginning of academic year: retrospective cohort study
Haller et al BMJ 2009; 339: b3974
"Don't get admitted to the hospital in July" is advice that is commonly passed around, based on the belief that the quality of patient care is poorer in July, when the new batch of residents typically starts in the US. This transition period when trainees begin their training has been called 'the July phenomenon' in the US and the 'August killing season' in the UK based on the belief that this is the most dangerous period of the year to be admitted to the hospital.
This belief persists, even though numerous studies that have not been able to prove that patient outcomes are worse in the months immediately after an influx of new trainees arrives. In a recent study however, Haller and colleagues were able to show that there is indeed some truth to the belief that patient care by new trainees leads to more adverse events.
In this study, the authors analyzed data on adverse events related to anesthetic procedures. In their hospital (Alfred Hospital in Melbourne, Australia), a special form is completed for every anesthetic procedure - this form asks the trainee to report, for every single procedure, whether or not each of 44 predefined incidents occurred. Examples of these events, which the authors call 'undesirable events,' are central and peripheral nerve injury, inadequate oxygenation, vomiting/aspiration in the OR, technical failure of endotracheal intubation, accidental upper airway obstruction, respiratory arrest during local-regional anesthesia, technical failure of arterial line insertion, uncontrolled hypertension, and uncontrolled hypotension.
The authors analyzed the accumulated data from such reporting, on procedures performed by trainees between October 1995 - December 2000. In Australia, the new trainees usually start on February 1.
After adjusting for case mix using a clustered multivariate analysis, the authors found that the number of adverse incidents per 1000 patient hours of procedures was higher in the first month of academic training than in the rest of the year (137 vs 107 per 1000 patient hours, a 40% higher adjusted rate, p < 0.001).
Surprisingly, they also found that trainees at all levels of training, even those in their fifth year of training had higher rates of undesirable events in the first month compared to the rest of the year. (Note: all these trainees, even those at higher levels, were working in this hospital for the first time. In Australia it is common for trainees work in multiple hospitals through their years of training, and not stay in one program throughout).
The authors' speculate that their results are different from those of other previous studies on this topic because they collected detailed data on each patient (instead of analyzing administrative databases like some other studies), had a larger sample size than other studies, and studied anesthesia care, which is inherently a riskier specialty than other medical specialties.
This study clearly shows the existence of a learning curve for trainees (at least in anesthesia) and also emphasizes that trainees at more advanced levels are still at higher risk of committing errors in the first month, perhaps because of unfamiliarity with the work environment (remember that even the advanced trainees were new to this hospital), excessive cross coverage, poor handovers, and insufficient supervision.
The authors suggest that adverse events in the early part of the academic year can be prevented by improving the orientation of trainees, using simulation, not assigning clinical tasks to trainees right from day one of training, systematic use of well documented standard working practices, teamwork training, and closer supervision.
