Effect of Flexible Duty Hour Policies on Length of Stay for Complex Intra-Abdominal Operations: A Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial Analysis

J Am Coll Surg. 2017 Feb;224(2):143-148.e1. doi: 10.1016/j.jamcollsurg.2016.10.040. Epub 2016 Nov 21.


Background: Changes to resident duty hour policies in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial could impact hospitalized patients' length of stay (LOS) by altering care coordination. Length of stay can also serve as a reflection of all complications, particularly those not captured in the FIRST trial (eg pneumothorax from central line). Programs were randomized to either maintaining current ACGME duty hour policies (Standard arm) or more flexible policies waiving rules on maximum shift lengths and time off between shifts (Flexible arm). Our objective was to determine whether flexibility in resident duty hours affected LOS in patients undergoing high-risk surgical operations.

Study design: Patients were identified who underwent hepatectomy, pancreatectomy, laparoscopic colectomy, open colectomy, or ventral hernia repair (2014-2015 academic year) at 154 hospitals participating in the FIRST trial. Two procedure-stratified evaluations of LOS were undertaken: multivariable negative binomial regression analysis on LOS and a multivariable logistic regression analysis on the likelihood of a prolonged LOS (>75th percentile).

Results: Before any adjustments, there was no statistically significant difference in overall mean LOS between study arms (Flexible Policy: mean [SD] LOS 6.03 [5.78] days vs Standard Policy: mean LOS 6.21 [5.82] days; p = 0.74). In adjusted analyses, there was no statistically significant difference in LOS between study arms overall (incidence rate ratio for Flexible vs Standard: 0.982; 95% CI, 0.939-1.026; p = 0.41) or for any individual procedures. In addition, there was no statistically significant difference in the proportion of patients with prolonged LOS between study arms overall (Flexible vs Standard: odds ratio = 1.028; 95% CI, 0.871-1.212) or for any individual procedures.

Conclusions: Duty hour flexibility had no statistically significant effect on LOS in patients undergoing complex intra-abdominal operations.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Abdomen / surgery
  • Adult
  • Aged
  • Digestive System Surgical Procedures*
  • Female
  • General Surgery / education*
  • General Surgery / organization & administration
  • Herniorrhaphy*
  • Humans
  • Internship and Residency / organization & administration*
  • Length of Stay / statistics & numerical data*
  • Logistic Models
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care
  • Personnel Staffing and Scheduling / standards*
  • Practice Guidelines as Topic
  • Prospective Studies
  • Quality Indicators, Health Care / statistics & numerical data
  • United States
  • Workload / standards*