1. Effect Of European Working Time Directive On Training And Outcome Following Coronary Artery Bypass Grafting Mohamad Bashir, Mark Field, Abbas Rashid, Matthew Shaw, Aung Oo Liverpool Heart & Chest Hospital

2. EWTD-Introduction The European Work Time Directive (EWTD) started in August 2004. In August 2009, full EWTD implementation resulted in a 48 hour “Maximum Legal Average” working week.

3. OBJECTIVES & METHODS Examine the effect of the 2004 (EWTD) (56 hours) on: – Trainee vs. consultant led cases – Adverse outcome: bleeding prolonged ventilation myocardial infarction in-hospital mortality Propensity methodology

4. Patients EuroSCORE - Pre EWTD Trainee (n=180)Consultant (n=1857)p Value EuroSCORE3.53.60.81 Logistic EuroSCORE4.14.40.73 Trainee (n=210) Consultant (n=1619)p Value EuroSCORE3.54.00.26 Logistic EuroSCORE3.85.10.32 Patients EuroSCORE - Post EWTD

5. Year of Training & Patients EuroSCORE – Pre EWTD Year of Training & Patients EuroSCORE – Post EWTD Clinical Fellow Locum Registrar SPR (1,2)SPR (3,4)SPR (5,6) Number of first operator cases 1612165482 Mean EuroSCORE3.32.7 4.03.6 Clinical Fellow Locum Registrar SPR (1,2)SPR (3,4)SPR (5,6) Number of first operator cases 29386885 Mean EuroSCORE3.22.34.93.83.6

6. Pre & Post EWT Directive – Adjusted CABG Outcome Data Trainee (n=180) Consultant (n=1857) p Value In-hospital mortality (%)1.22.80.16 Follow-up mortality (%)4.84.10.86 Myocardial Infarction (%)0.62.00.14 Stroke (%)1.61.70.92 Renal failure (%)5.15.00.93 Re-exploration for bleeding (%) 3.13.80.62 Gastrointestinal complications (%) 0.50.70.67 Ventilation >24 hours (%)2.64.30.28 Deep sternal wound infection (%) 2.33.80.47 Trainee (n=210) Consultant (n=1619) p Value In-hospital mortality (%)1.62.70.36 Follow-up mortality (%)3.25.10.23 Myocardial Infarction (%)3.52.30.36 Stroke (%)1.6 0.96 Renal failure (%)0.04.4<0.05 Re-exploration for bleeding (%)4.65.40.68 Gastrointestinal complications (%) 2.81.70.20 Ventilation >24 hours (%)4.44.20.90 Deep sternal wound infection (%) 1.92.70.54

7. Kaplan-Meier curve Post EWT DirectivePre EWT Directive

8. RESULTS Outcomes of trainee led cases before & after the EWTD: – Preoperative patient demographics and risk factors were not significantly different (based on Euroscore) – Training opportunity (i.e. trainee led cases against total number of trainee assisted cases) was not different – Primary outcome measure of in-hospital mortality was not different – Secondary outcome measures (bleeding, prolonged ventilation, myocardial infarction) was not different Outcomes of consultant led cases: – were not adversely affected by the EWTD – did not differ significantly from trainee outcomes

9. CONCLUSIONS The EWTD had no significant adverse effect on training opportunities and in-hospital mortality of trainee led cases & adverse outcomes.