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Background: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery., Methods: A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality., Results: A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented., Conclusions: Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.

Objectives: To determine if reducing prehospital time and time-to-craniotomy is associated with decreased mortality in trauma patients with acute subdural hematomas., Background: Time-to-treatment is an important performance filter for trauma systems, yet very little evidence exists to support its use. Despite the biological rationale supporting the notion of the "Golden Hour" for trauma patients, no evidence exists to support it. Likewise, it remains controversial whether or not time-to-craniotomy is associated with survival in patients with subdural hematomas. Previous studies may have been affected by selection bias., Methods: Retrospective cohort study of all trauma patients who arrived directly from the scene of injury. Study patients were all patients with acute subdural hematomas and without severe torso injuries, who required craniotomy at a Canadian level 1 trauma center from January 1 1996 to December 31 2007. The independent variables of interest were prehospital time and time-to-craniotomy. The primary outcome measure was in-hospital mortality., Results: Of 12,105 trauma patients assessed, 149 patients met inclusion criteria. Overall, 40% (n = 60) patients died. On univariate analysis, there was a strong trend suggesting that patients arriving within the "Golden Hour after trauma" had decreased mortality (37% vs. 53%, P = 0.09). However, there was no difference in mortality for patients undergoing craniotomy within 4 hours and after 4 hours (42% vs. 36%, P = 0.4). On multivariate logistic regression, increased prehospital time was found to be associated with increased mortality (odds ratio 1.03 per minute, 95% CI 1.004-1.05, P = 0.024). Surprisingly, there was a trend showing that increased trauma room to craniotomy times were associated with lower mortality (odds ratio 0.995 per minute, 95% CI 0.99-1.0, P = 0.056). However, patients who quickly had their craniotomy seemed to have more severe neurological injury., Conclusion: Rapid transport of patients with traumatic subdural hematomas hospital is associated with decreased mortality.