Policy of the Graduate Medical Education Committee
Section: Resident Supervision/ Work Environment
Subject: Duty Hours and Work Environment
Number: 3.200
Date Developed: 7/98
Last Review/Revision: 10/04, 1/08
Replaces: Previous policy of same name, dated 5/03
ACGME Requirements: Institutional II.D.i., II.F; Common VI; RRC Procedures
for Granting Duty Hours Exceptions
Purpose
To establish University of Arkansas for Medical Sciences College of Medicine
standards for duty hours and work environment for residents (includes fellows).
Definitions
Duty hours: all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences, didactic sessions or assigned research duties. Duty hours do not include reading and preparation time spent away from the duty site.
In-house call: those duty hours beyond the normal workday when residents are required to be immediately available in the assigned institution.
At-home call (pager call): call taken from outside the assigned institution.
Ancillary support: defined as, but not limited to, the following: Drawing blood, obtaining EKGs, transporting patients, securing medical records, securing tests results, completing forms to order tests and studies, monitoring patients after procedures. Except in unusual circumstances, providing ancillary support should not be the resident’s responsibility except for specific educational objectives or as necessary for patient care.
Policy
Background: Providing residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Each Program Director must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. The Program Director must establish an environment that is optimal both for resident education and for patient care, while ensuring undue stress and fatigue among residents are avoided. Both faculty and residents must be educated on the signs and symptoms of fatigue. It is the Program Director’s responsibility to ensure assignment of appropriate duty hours so that residents are not required to perform excessively difficult or prolonged duties regularly. However, duty hours must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. The structuring of duty hours and on call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident.
Each Program Director must establish and implement formal departmental written policies and procedures governing duty hours and work environment for residents, which comply with this institutional GMEC policy and the Common and Specialty-specific Program Requirements. Different rotations may require different duty hours and patterns; however, the following guidelines for duty hours and work environment apply:
Duty Hours
1.
Duty hours must be limited to 80 hours per week, averaged over a
four-week period, inclusive of all in-house call activities.
2.
Residents must be provided with one day in 7 free from all educational
and clinical responsibilities, averaged over a 4-week period,
inclusive of call. One day is defined as one
continuous 24-hour period free from all clinical, educational, and
administrative activities.
3.
If a resident
takes vacation or other leave, ACGME requires that vacation or leave days be
taken out of the numerator and the denominator for calculating
duty hours, call frequency or days off (i.e., if a resident is on vacation for
one week, the hours for that rotation should be averaged over the remaining
three weeks. The standards do not permit a “rolling average,” because it may
mask compliance problems by averaging across high and low duty hour rotations.
The rotation with the greatest hours and frequency of call must comply with the
common duty hour standards. The program requirements for Internal Medicine do
not permit averaging of the interval between in-house call. The ACGME expects
that duty hours during the rotation with the greatest hours and frequency of
call comply with the common standards.
4. Adequate
time for rest and personal activities must be provided. This should consist of a
10-hour time period provided between all daily
duty periods and after in-house call.
On-Call Activities
The goal of on-call activities is to provide residents with continuity of
patient care experiences throughout a 24-hour period.
1. In-house call:
a. Must occur no more frequently than every third night, averaged over a four-week period.
b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours.
c. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements.
d. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted after 24 hours of continuous duty.
2. At-home call (pager call):
a. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident.
b. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.
c. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.
d. The Program Director and the teaching faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
Work Environment
Food Services: Residents on duty must have access to adequate and appropriate food services. Food is provided to residents who take in-house call.
Call Rooms: Call rooms are provided for residents who take in-house call.
Support Services: Adequate ancillary support for patient care shall be provided for residents at all times. Laboratory/pathology/radiology services: these services and the associated information systems must be available and adequate to support timely and quality patient care.
Medical Records: Medical records system that document the course of each patient’s illness and care must be available at all time and must be adequate to support quality patient care, the education of residents, quality assurance and provide a resource for scholarly activity.
Security/safety: Appropriate security and personal safety measures must be provided to residents at all locations.
1. Each program must have written policies and procedures consistent with the Institutional and Program Requirements for resident duty hours and the working environment. These policies and procedures must be distributed to the residents and the faculty.
2. Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
3. Each Program Director should review each resident’s rotational schedule to assure compliance with this institutional policy and the Common Program Requirements.
4. Each Program Director should regularly monitor resident duty hours for compliance with this institutional policy and the Common Program Requirements. Monitoring of duty hours is required with frequency sufficient to ensure an appropriate balance between education and service.
5. The GMEC shall monitor compliance with this policy through the:
a. Internal review of each program
b. Annual GME Survey of residents
c. Periodic monitoring of individual programs
Falsification of duty hour’s data or pressure to cause the falsification of such data is considered egregious behavior for residents and can result in disciplinary action to include dismissal. Faculty members are governed by the Faculty Group Practice and University policies and procedures and terms of the Faculty Group Practice agreement. Residents must notify the Program Director of requests or pressure to work in excess of duty hours authorized by this policy.
Duty Hours Exceptions
1. The Program Director must submit a written request for an exemption to the GMEC Chair. The request must clearly document the following:
a. Patient Safety: Information must be submitted that describes how the program and institution will monitor, evaluate, and ensure patient safety with extended resident work hours.
b. Educational Rationale: The request must be based on a sound educational rationale which should be described in relation to the program's stated goals and objectives for the particular assignments, rotations, and level(s) of training for which the increase is requested. Blanket exceptions for the entire educational program should be considered the exception, not the rule.
c. Moonlighting Policy: Specific information regarding the program's moonlighting policies for the periods in question must be included.
d. Call Schedules: Specific information regarding the resident call schedules during the times specified for the exception must be provided.
e. Faculty Monitoring: Evidence of faculty development activities regarding the effects of resident fatigue and sleep deprivation must be appended.
2. The Program Director will present the request in person to the GMEC for discussion..
3. If approved by the GMEC, the Designated Institutional Official (DIO) or the GMEC Chair will provide a documented written statement of institutional endorsement of the proposal.
4. The Program Director must submit the request to the RRC according to the ACGME’s RRC Procedures for Granting Duty Hours Exceptions. The proposal to the RRC must include a copy of this policy (which contains the institution's written procedures and criteria for endorsing requests for an exception to the duty hours limits) and the current accreditation status of the program and of the sponsoring institution.