Study finds rise in rate of undesirable events at start of academic year

The rate of undesirable events in teaching hospitals increases at the beginning of the academic year, regardless of trainees' level of clinical experience, concludes new research from Australia published on bmj.com today.

At the beginning of an academic year, teaching hospitals around the world accept an influx of new trainees and fellows, and doctors who are already in specialist training move on to the next post within their training scheme. This transition phase is often considered to be the worst time of the year to be admitted to hospital. Previous studies have been inconclusive, but most have concluded that the quality of care remains uniform throughout the academic year.

To investigate this further, an international team of researchers set out to examine whether patients having an anaesthetic procedure carried out by first to fifth year trainees at the beginning of the academic year had a higher rate of undesirable events than patients operated on later in the year. They also analysed the trend in the rate of undesirable events throughout the year.

Using administrative and patient record data from a University affiliated hospital in Melbourne, Australia, the team analysed 19,560 patients over a period of five years (1995-2000).

The rate of undesirable events was higher at the beginning of the academic year compared with the rest of the year (137 v 107 events per 1000 patient hours).

This excess risk was seen for all trainees regardless of their level of clinical experience, suggesting that seniority of trainees does not protect patients from undesirable events.

The effect decreased progressively after the first month, and the trend disappeared fully after the fourth month of the year, particularly for events related to technical performance and overall management of patients.

The fact that more experienced trainees have as many undesirable events as new trainees suggests that lack of technical skills is not the only mechanism explaining this phenomenon, say the authors. They suggest that new trainees are unfamiliar with the working environment, supervision is insufficient, and communication suffers.

Possible strategies to minimise this include improving trainees' orientation and integration during their first weeks of employment, increasing intensity of supervision of advanced trainees, and developing early training sessions aimed at improving technical and teamwork skills, they conclude.

These findings suggest that the current clinical system cannot absorb the effects of new personnel at the beginning of a new academic year, say researchers in an accompanying editorial.

Professor Paul Barack from Utrecht Medical Center in the Netherlands and Professor Julie Johnson from the University of New South Wales in Australia believe that reducing variation in patient care at the start of the academic year requires developing resilient systems in which individuals, teams, and their organisations can adapt and compensate for the disruptions of incoming inexperienced trainees.

Trainees need practice and mentorship, with increased patient awareness, closer supervision, and graduated clinical responsibilities, they conclude.

October 13, 2009